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Sankararaman S, Freeman AJ. Early detection of hepatobiliary involvement in cystic fibrosis: Biomarkers, radiologic methods, and genetic influences. Pediatr Pulmonol 2024; 59 Suppl 1:S107-S114. [PMID: 39105338 DOI: 10.1002/ppul.26892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 01/10/2024] [Accepted: 01/21/2024] [Indexed: 08/07/2024]
Abstract
Cystic fibrosis-related hepatobiliary involvement (CFHBI) is a term used to describe a spectrum of hepatobiliary involvement ranging from a transient elevation of transaminase levels to advanced cystic fibrosis-associated liver disease (aCFLD). While CFHBI is common among people with cystic fibrosis (PwCF), aCFLD is rare impacting only approximately 5%-10% of the CF population. After respiratory/cardiorespiratory issues and transplant-related complications, aCFLD is now the 4th leading cause of mortality among PwCF. Additionally, aCFLD is an independent predictor of all-cause mortality and is associated with significant morbidity. Despite this recognition, our ability to predict those patients at greatest risk for aCFLD, identify early aCFLD, and monitor the incremental progression of CFHBI is lacking. Here, we review the strengths and weaknesses of the common biomarkers and imaging modalities used in the evaluation and monitoring of CFHBI, as well as the current understanding of genetic modifiers related to aCFLD.
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Affiliation(s)
- Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
- Case Western Reserve University SOM, Cleveland, Ohio, USA
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Nationwide Children's Hospital, Columbus, Ohio, USA
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2
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Eldredge JA, Oliver MR, Ooi CY. Cystic fibrosis liver disease in the new era of cystic fibrosis transmembrane conductance regulator (CFTR) modulators. Paediatr Respir Rev 2024; 50:54-61. [PMID: 38281822 DOI: 10.1016/j.prrv.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 12/21/2023] [Indexed: 01/30/2024]
Abstract
Cystic fibrosis liver disease (CFLD) is characterised by a wide heterogenity of manifestations and severity. It represents a major cause of morbidity in people with cystic fibrosis (PwCF), which will be of increasing relevance as survival increases in the new era of cystic fibrosis care. No medical therapy currently available has evidence to treat or prevent progression of liver disease. Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) modulators may be transformative on pulmonary, nutritional and quality of life, but direct effect on long term liver disease outcomes is not yet established. Drug-associated hepatic adverse effects may be common, and clinician familiarity with drug-monitoring recommendations is essential. Longitudinal studies are required to understand the effect of CFTR modulators on the incidence and natural history of CFLD, including with early treatment initiation, in established advanced liver disease, and post liver transplantation.
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Affiliation(s)
- Jessica A Eldredge
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Australia.
| | - Mark R Oliver
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Australia.
| | - Chee Y Ooi
- Department of Gastroenterology, Sydney Children's Hospital Randwick, NSW, Australia; School of Clinical Medicine, Discipline of Paediatrics and Child Health, UNSW Medicine & Health, University of New South Wales, Sydney, Australia.
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3
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Bodewes FAJA, Freeman AJ, Weymann A, Debray D, Scheers I, Verkade HJ, Narkewicz MR. Towards a Standardized Classification of the Hepatobiliary Manifestations in Cystic Fibrosis (CFHBI): A Joint ESPGHAN/NASPGHAN Position Paper. J Pediatr Gastroenterol Nutr 2024; 78:153-165. [PMID: 38291686 DOI: 10.1097/mpg.0000000000003944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/08/2023] [Indexed: 02/01/2024]
Abstract
The broad spectrum of hepatobiliary involvement in cystic fibrosis (CF) has been commonly referred to as cystic fibrosis liver disease (CFLD). However, differences in the definitions of CFLD have led to variations in reported prevalence, incidence rates, and standardized recommendations for diagnosis and therapies. Harmonizing the description of the spectrum of hepatobiliary involvement in all people with CF (pwCF) is deemed essential for providing a reliable account of the natural history, which in turn supports the development of meaningful clinical outcomes in patient care and research. Recognizing this necessity, The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) commissioned and tasked a committee to develop and propose a systematic classification of the CF hepatobiliary manifestations to increase uniformity, accuracy, and comparability for clinical, registry, and research purposes. This report describes the committee's combined expert position statement on hepatobiliary involvement in CF, which has been endorsed by NASPGHAN and ESPGHAN. We recommend using CFHBI (Cystic Fibrosis Hepato-Biliary Involvement) as the updated term to describe and classify all hepatobiliary manifestations in all pwCF. CFHBI encompasses the current extensive spectrum of phenotypical, clinical, or diagnostic expressions of liver involvement observed in pwCF. We present a schematic categorization of CFHBI, which may also be used to track and classify the changes and development of CFHBI in pwCF over time. The proposed classification for CFHBI is based on expert consensus and has not been validated for clinical practice and research purposes. Achieving validation should be an important aim for future research.
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Affiliation(s)
- Frank A J A Bodewes
- Division of Pediatric Gastroenterology/Hepatology, Beatrix Children's Hospital/University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Alvin Jay Freeman
- Division of Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Alexander Weymann
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH
| | - Dominique Debray
- Pediatric Hepatology Unit, Assistance Publique-Hôpitaux de Paris (APHP)-Hôpital Necker-Enfants maladies, Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Paris, France
| | - Isabelle Scheers
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Henkjan J Verkade
- Division of Pediatric Gastroenterology/Hepatology, Beatrix Children's Hospital/University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Michael R Narkewicz
- Digestive Health Institute, Children's Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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Dajti E, Ravaioli F, Paiola G, Volpi S, Colecchia L, Ferrarese A, Alemanni LV, Cusumano C, Di Biase AR, Marasco G, Vestito A, Festi D, Rautou PE, Cipolli M, Colecchia A. The non-invasive evaluation of liver involvement in patients with cystic fibrosis: A prospective study. Liver Int 2023; 43:2492-2502. [PMID: 37724776 DOI: 10.1111/liv.15748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/25/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND AND AIMS Porto-sinusoidal vascular disease (PSVD) has been described as the prominent pathology in liver explants of patients with cystic fibrosis (CF), but data outside the transplant setting are lacking. We aimed to investigate the prevalence of portal hypertension (PH) in CF-associated liver disease (CFLD) and develop an algorithm to classify liver involvement in CF patients. METHODS This is a cross-sectional study of consecutive paediatric and adult patients in a tertiary centre between 2018 and 2019, who underwent ultrasound, liver (LSM) and spleen stiffness (SSM) measurement. CFLD was defined according to physical examination, liver tests and ultrasound findings. PSVD was likely if there were PH signs in the absence of advanced chronic liver disease (CF-ACLD, LSM <10 kPa). A historical cohort was used to validate the prognostic significance of the new definitions. RESULTS Fifty (27.5%) patients met CFLD criteria. At least one sign of PH was found in 47 (26%) patients, but most (81%) had LSM <10 kPa and were likely to have PSVD; only 9 (5%) had CF-ACLD. PSVD and CFLD (LSM <10 kPa) co-existed in most (23/36) cases. In the historical cohort (n = 599 patients), likely PSVD and CFLD+PH were independently associated with a 2-fold and 3.5-fold increase in mortality compared to patients without PH, respectively. In 34 patients with SSM, values <21 and >50 kPa accurately diagnosed specific signs of PH. CONCLUSIONS PSVD is the prevailing cause of PH in CF patients. We developed a new diagnostic algorithm based on clinical and elastosonography criteria to classify liver involvement in patients with CF.
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Affiliation(s)
- Elton Dajti
- Unit of Gastroenterology, Borgo Trento University Hospital of Verona, Verona, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S. Orsola, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Paiola
- Cystic Fibrosis Center, Borgo Trento University Hospital of Verona, Verona, Italy
| | - Sonia Volpi
- Cystic Fibrosis Center, Borgo Trento University Hospital of Verona, Verona, Italy
| | - Luigi Colecchia
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Alberto Ferrarese
- Unit of Gastroenterology, Borgo Trento University Hospital of Verona, Verona, Italy
| | | | - Caterina Cusumano
- Unit of Gastroenterology, Borgo Trento University Hospital of Verona, Verona, Italy
| | | | - Giovanni Marasco
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S. Orsola, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Amanda Vestito
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S. Orsola, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Pierre-Emmanuel Rautou
- Centre de Recherche sur L'inflammation, Université Paris-Cité, Inserm, UMR 1149, Paris, France
- Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Clichy, France
| | - Marco Cipolli
- Cystic Fibrosis Center, Borgo Trento University Hospital of Verona, Verona, Italy
| | - Antonio Colecchia
- Unit of Gastroenterology, Borgo Trento University Hospital of Verona, Verona, Italy
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
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Lusman SS. Update on Cystic Fibrosis in Pediatric Patients. Curr Gastroenterol Rep 2023; 25:308-315. [PMID: 37653358 DOI: 10.1007/s11894-023-00896-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE OF REVIEW Cystic fibrosis is an inherited, multisystem disease that affects the gastrointestinal system in numerous ways. This article reviews the nutritional, gastrointestinal, and hepatobiliary manifestations of cystic fibrosis with an emphasis on the effects of CFTR modulator therapy. RECENT FINDINGS The life expectancy of individuals with cystic fibrosis has increased substantially in recent years. CFTR modulator therapy improves pulmonary function and results in weight gain. An individualized approach to nutrition is encouraged. Pancreatic exocrine function may improve with intervention early in life. The use of non-invasive methods to screen for hepatobiliary involvement is recommended. Highly effective CFTR modulators lead to increased survival and improved quality of life for many individuals. Their effects on gastrointestinal symptoms and hepatobiliary disease are not fully understood. Patient-reported outcome measures and biomarkers are important clinical endpoints for studying the effects of modulators.
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Affiliation(s)
- Sarah Shrager Lusman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, 622 West 168th Street, PH 17 East - 105L, New York, NY, 10032, USA.
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Scott JA, Jones AM, Jokl E, Gordon-Walker T, Barry PJ, Hanley NA, Piper Hanley K, Athwal VS. Improving detection of cystic fibrosis related liver disease using liver fibrosis assessment tools. Heliyon 2023; 9:e21861. [PMID: 38053913 PMCID: PMC10694159 DOI: 10.1016/j.heliyon.2023.e21861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 10/06/2023] [Accepted: 10/30/2023] [Indexed: 12/07/2023] Open
Abstract
Background & aims Cystic Fibrosis related liver disease (CFLD) is the 3rd largest cause of death in Cystic Fibrosis (CF). As advances in pulmonary therapies have increased life-expectancy, CFLD has become more prevalent. Current guidelines may underdiagnose liver fibrosis, particularly in its early stages. Newer modalities for the assessment of fibrosis may provide a more accurate assessment. FibroScan is validated in assessing fibrosis for several aetiologies including alcohol and fatty liver, the CFLD cohort have an entirely different phenotype so the cut off values are not transferrable. We appraised fibrosis assessment tools to improve diagnosis of CFLD. Methods A prospective cohort (n = 114) of patients from the Manchester Adult Cystic Fibrosis Centre, UK were identified at annual assessment. Demographic data including co-morbidity, CFTR genotyping, biochemistry and imaging were used alongside current guidelines to group into CFLD and CF without evidence of liver disease. All patients underwent liver stiffness measurement (LSM) and assessment of serum-based fibrosis biomarker panels. A new diagnostic criterion was created and validated in a second, independent cohort. Results 12 of 114 patient classified as CFLD according to the European Cystic Fibrosis Society best practice guidelines. No specific risk factors for development of CFLD were identified. Liver enzymes were elevated in patients with CFLD. Serum biomarker panels did not improve diagnostic criteria. LSM accurately predicted CFLD. A new diagnostic criterion was proposed and validated in a separate cohort, accurately predicating CFLD in 10 of 32 patients (31 %). Conclusion We present a cohort of patients with CF assessed for the presence of liver fibrosis using blood biomarkers and LSM based platforms. We propose a new, simplified diagnostic criteria, capable of accurately predicting liver disease in patients with CF.Clinical trials number: NCT04277819.
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Affiliation(s)
- Jennifer A. Scott
- Division of Diabetes, Endocrine and Gastroenterology, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
- Division of Gastroenterology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Andrew M. Jones
- Adult Cystic Fibrosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Elliot Jokl
- Division of Diabetes, Endocrine and Gastroenterology, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Timothy Gordon-Walker
- Department of Hepatology, Scotland Liver Transplant Unit, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Peter J. Barry
- Adult Cystic Fibrosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Neil A. Hanley
- Division of Diabetes, Endocrine and Gastroenterology, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
- Directorate of Research and Innovation, Manchester University NHS Foundation Trust, Manchester, UK
| | - Karen Piper Hanley
- Division of Diabetes, Endocrine and Gastroenterology, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
- Directorate of Research and Innovation, Manchester University NHS Foundation Trust, Manchester, UK
- Wellcome Trust Centre for Cell Matrix Research, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Varinder S. Athwal
- Division of Diabetes, Endocrine and Gastroenterology, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
- Division of Gastroenterology, Manchester University NHS Foundation Trust, Manchester, UK
- Directorate of Research and Innovation, Manchester University NHS Foundation Trust, Manchester, UK
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Sakhuja S, Staples HM, Minard CG, Ramm LE, Lewindon PJ, Ramm GA, Leung DH. Risk factors for more rapid progression of severe liver fibrosis in children with cystic fibrosis-related liver disease: A multi-center study validated by liver biopsy. Liver Int 2023; 43:1277-1286. [PMID: 37035868 DOI: 10.1111/liv.15572] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/15/2023] [Accepted: 03/18/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND AND AIMS Early identification of risk factors for the development of severe fibrosis in children with cystic fibrosis-related liver disease (CFLD) is crucial as promising therapies emerge. METHODS This multi-center cohort study of children with a priori defined CFLD from 1999 to 2016, was designed to evaluate the clinical utility of CF-specific characteristics and liver biomarkers assessed years prior to liver biopsy-proven CFLD to predict risk of developing severe fibrosis (F3-4) over time. Fibrosis was staged by Metavir classification. RESULTS The overall study cohort of 42 patients (F0-2 (n = 22) and F3-4 (n = 20)) was 57% male (n = 24) with median age of 7.6 years at baseline visit versus 10.3 years at biopsy. Median FEV1 % predicted was lower in F3-4 participants at baseline versus F0-2 (59% vs. 85%; p = .002), while baseline FIB-4, APRI and GGT were higher in F3-4. Median splits for FIB-4 (≥.13), APRI (≥.36), GPR (≥.09), GGT (≥25.5), and FEV1 % (<64%) were associated with more rapid progression to F3-4 (p < .01 for all). Using a combination of change/year in FIB-4, APRI, and GPR to predict F3-4, the AUROC was .81 (95% CI, .66, .96; p < .0001). For up to 5.8 years prior, thresholds for GPR were met 6.5-fold more rapidly, and those for APRI and FIB-4 were met 2.5-fold more rapidly, in those who progressed to F3-4 than those that did not. CONCLUSIONS This study suggests mild-moderate pulmonary dysfunction and higher liver biomarker indices at baseline may be associated with faster progression of CFLD.
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Affiliation(s)
- Shruti Sakhuja
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Gastroenterology, Hepatology, Nutrition, Texas Children's Hospital, Houston, Texas, USA
| | - Heather M Staples
- Department of Pediatrics, University of South Carolina School of Medicine, Columbia, South Carolina, USA
- Division of Pediatric Pulmonology, Prisma Health Children's Hospital-Midlands, Columbia, South Carolina, USA
| | - Charles G Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas, USA
| | - Louise E Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Peter J Lewindon
- Department of Gastroenterology, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Grant A Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Daniel H Leung
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Gastroenterology, Hepatology, Nutrition, Texas Children's Hospital, Houston, Texas, USA
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Ozdogan E, Arikan C. Liver fibrosis in children: a comprehensive review of mechanisms, diagnosis, and therapy. Clin Exp Pediatr 2023; 66:110-124. [PMID: 36550776 PMCID: PMC9989719 DOI: 10.3345/cep.2022.00367] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 09/14/2022] [Indexed: 12/23/2022] Open
Abstract
Chronic liver disease incidence is increasing among children worldwide due to a multitude of epidemiological changes. Most of these chronic insults to the pediatric liver progress to fibrosis and cirrhosis to different degrees. Liver and immune physiology differs significantly in children from adults. Because most of pediatric liver diseases have no definitive therapy, a better understanding of population and disease-specific fibrogenesis is mandatory. Furthermore, fibrosis development has prognostic significance and often guide treatment. Evaluation of liver fibrosis continues to rely on the gold-standard liver biopsy. However, many high-quality studies put forward the high diagnostic accuracy of numerous diagnostic modalities in this setting. Herein, we summarize and discuss the recent literature on fibrogenesis with an emphasis on pediatric physiology along with a detailed outline of disease-specific signatures, noninvasive diagnostic modalities, and the potential for antifibrotic therapies.
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Affiliation(s)
- Elif Ozdogan
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Cigdem Arikan
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Koc University School of Medicine, Istanbul, Turkey
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Hamed DH, Ibrahim RSM, Hakim MA, Mohsen M. Insight into clinical, laboratory, and GIT ultrasound diagnostic findings of cystic fibrosis in pediatrics. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2022. [DOI: 10.1186/s43054-022-00129-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Abstract
Background
Cystic fibrosis (CF) is a multisystem disorder. Gastrointestinal tract (GIT) involvement presently requires medical attention, and this improves the survival rate of patients with CF. GIT imaging has an essential role in the early detection of GIT affection. This study aimed to quantify the abdominal symptoms and their relationship to clinical findings, abdominal ultrasound scoring system, and laboratory parameters, correlating GIT manifestation with ultrasound diagnostic findings.
Methods
This was a cross-sectional study that included 60 patients diagnosed with CF based on clinical manifestations and confirmed by a positive sweat chloride test ≥ 60 mmol/L and/or genetic analysis (CFTR gene mutation; a copy from each parent) in the CF clinic in the Children’s Hospital, in a period of 12 months.
Results
Recurrent abdominal pain (RAP) was the most common GIT manifestation, followed by abdominal distension and steatorrhea. Ultrasonography (US) showed that the most frequent findings were pancreatic lipomatosis in 16 patients (26.7%), the next common finding was heterogeneous coarse hepatic parenchyma in 14 patients (23.3%), while the least finding was the thickened bowel walls in 2 patients (3.3%). Abdominal US scoring revealed that the highest burden of GIT symptoms was clearly associated with pancreatic lipomatosis and liver steatosis with the highest score (6/7) (p = 0.048), while bowel wall thickness (BWT) had the lowest score (3/7) (Table 4).
Conclusion
This study reveals that abdominal US is a non-invasive investigation that helps in the early detection of GIT involvement in CF. RAP is a common GIT manifestation and may reflect a major pathology. Moreover, a significant relationship was detected between RAP and pancreatic cystosis and lipomatosis. Therefore, the study also highlights the importance of US as a routine non-invasive follow-up tool for patients with CF and suggests close monitoring of patients with CF by abdominal US performed every 6 to 12 months.
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10
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Issa Z, Gohy S, Zech F, Baldin P, Delire B, Dahlqvist G. Prevalence and characteristics of cystic fibrosis liver disease: a study highlighting the lack of histological diagnosis. Clin Res Hepatol Gastroenterol 2022; 46:101977. [PMID: 35772685 DOI: 10.1016/j.clinre.2022.101977] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/24/2022] [Accepted: 06/08/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Cystic fibrosis liver disease (CFLD) is the third leading cause of death in patients with cystic fibrosis (CF). We aim to determine the prevalence of CFLD in a cohort of adult patients with CF and to characterise liver involvement in this population highlighting the importance of histological diagnosis. METHODS We retrospectively studied a cohort of patients with CF. Inclusion criteria were age ≥ 18 and minimum 1 year of follow-up. We excluded lung transplant patients. CFLD was defined as having 2 out of 3 criteria: persistent elevation of transaminases and/or gamma-glutamyltransferase; abnormal ultrasound; and abnormal transient elastography. Non-invasive fibrosis biomarkers were calculated in CFLD patients. Adult-onset CFLD (Ad-CFLD) was defined as CFLD ≥18 years. Severe CFLD (s-CFLD) was defined as CFLD with cirrhosis and/or portal hypertension. RESULTS We included 113 patients. Median age was 29 years, 58 were male. Forty patients had CFLD. Median age at CFLD diagnosis was 10 years. Twenty-one patients had s-CFLD. Two s-CFLD patients had nodular regenerative hyperplasia, 1 had hepatocellular carcinoma and 4 underwent liver transplantation. Six patients had ad-CFLD. Both CFLD and s-CFLD groups were compared to a non-CFLD group. The CFLD group had significantly more males (p = 0.034). S-CFLD group had worse pulmonary function (p = 0.015). CONCLUSION Thirty five percent of adult patients with CF, mainly males, had CFLD. Nineteen percent had s-CFLD and had worse pulmonary function. With recent reports unravelling different pathophysiological mechanisms in CFLD, we believe it is important to better characterise liver involvement using liver biopsy.
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Affiliation(s)
- Zaina Issa
- Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
| | - Sophie Gohy
- Department of Pneumology, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Cystic Fibrosis Reference Center, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Francis Zech
- Department of Infectious Diseases, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Pamela Baldin
- Department of Anatomopathology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Bénédicte Delire
- Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Géraldine Dahlqvist
- Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Non-cirrhotic portal hypertension (obliterative portal venopathy) is the predominant form of chronic liver disease in cystic fibrosis. Ir J Med Sci 2022:10.1007/s11845-022-03153-0. [PMID: 36114932 DOI: 10.1007/s11845-022-03153-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/05/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cystic fibrosis (CF)-associated liver disease commonly manifests as portal hypertension and its complications. We investigated the proposal that the pathophysiology is of non-cirrhotic rather than cirrhotic portal hypertension. This distinction may have important implications for treatment. METHODS We compared liver transplant explants from cystic fibrosis patients with explants from patients with classical cholestatic diseases, primary biliary cholangitis and primary sclerosing cholangitis. Presence of cirrhosis, fibrosis, nodular regenerative hyperplasia, biliary and portal venous pathology were recorded. Quantitation of portal venules in representative section was performed. RESULTS Nine patients with cystic fibrosis liver disease, 7 primary biliary cholangitis (PBC) and 7 primary sclerosing cholangitis (PSC) were evaluated. Cirrhosis was present in 0/9 of CF patients and 11/14 of the PBC and PSC controls (p < 0.01). Nodular regenerative hyperplasia was present in 8/9 of the CF patients but none of the controls (p < 0.01). Portal venule numbers per 15 mm2 section were significantly lower in the CF patients 52 (20-72) compared to the primary biliary cholangitis 78 (47-110) and primary sclerosing cholangitis patients, 79 (41-134) (p < 0.05). Portal sclerotic nodules were found in all the CF patients but in only one of the controls (9/9 vs 1/14 p < 0.01). CONCLUSIONS This study demonstrates that non-cirrhotic portal hypertension or obliterative portal venopathy is the predominant hepatic pathophysiology in adult CF patients requiring liver transplantation. It suggests that treatments directed at the hepatic portal venous system may be more effective than current treatment directed at the biliary system in cystic fibrosis.
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12
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Sherwood JS, Ullal J, Kutney K, Hughan KS. Cystic fibrosis related liver disease and endocrine considerations. J Clin Transl Endocrinol 2022; 27:100283. [PMID: 35024343 PMCID: PMC8724940 DOI: 10.1016/j.jcte.2021.100283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/23/2021] [Accepted: 11/27/2021] [Indexed: 12/12/2022] Open
Abstract
Cystic fibrosis-liver disease (CFLD) is one of the most common non-pulmonary complications in the CF population, is associated with significant morbidity and represents the third leading cause of mortality in those with CF. CFLD encompasses a broad spectrum of hepatobiliary manifestations ranging from mild transaminitis, biliary disease, hepatic steatosis, focal biliary cirrhosis and multilobular biliary cirrhosis. The diagnosis of CFLD and prediction of disease progression remains a clinical challenge. The identification of novel CFLD biomarkers as well as the role of newer imaging techniques such as elastography to allow for early detection and intervention are active areas of research focus. Biliary cirrhosis with portal hypertension represents the most severe spectrum of CFLD, almost exclusively develops in the pediatric population, and is associated with a decline in pulmonary function, poor nutritional status, and greater risk of hospitalization. Furthermore, those with CFLD are at increased risk for vitamin deficiencies and endocrinopathies including CF-related diabetes, CF-related bone disease and hypogonadism, which can have further implications on disease outcomes and management. Effective treatment for CFLD remains limited and current interventions focus on optimization of nutritional status, identification and treatment of comorbid conditions, as well as early detection and management of CFLD specific sequelae such as portal hypertension or variceal bleeding. The extent to which highly effective modulator therapies may prevent the development or modify the progression of CFLD remains an active area of research. In this review, we discuss the challenges with defining and evaluating CFLD and the endocrine considerations and current management of CFLD.
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Key Words
- APRI, aspartate aminotransferase to platelet ratio
- BMI, body mass index
- CFBD, CF bone disease
- CFLD, Cystic fibrosis-liver disease
- CFRD, CF related diabetes
- CFTR, cystic fibrosis transmembrane conductance regulator
- Cirrhosis
- Cystic fibrosis liver disease
- Cystic fibrosis-related diabetes
- FFA, free fatty acids
- Fib-4, Fibrosis-4
- GH, growth hormone
- IGF-1, insulin-like growth factor-1
- Insulin resistance
- UDCA, ursodeoxycholic acid
- ULN, upper limit of normal
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Affiliation(s)
- Jordan S. Sherwood
- Department of Pediatrics, Diabetes Research Center, Division of Pediatric Endocrinology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Jagdeesh Ullal
- Department of Medicine, UPMC Center for Diabetes and Endocrinology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Katherine Kutney
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Kara S. Hughan
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, United States
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13
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Yavuz S, Pişkin FC, Oktay C, Tümgör G. Assessment of hepatic involvement by two-dimensional shear wave elastography in paediatric patients with cystic fibrosis. J Paediatr Child Health 2022; 58:459-462. [PMID: 34519139 DOI: 10.1111/jpc.15741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/16/2021] [Accepted: 08/28/2021] [Indexed: 11/28/2022]
Abstract
AIM This study aimed to investigate parenchymal changes in the liver in paediatric patients with cystic fibrosis (CF) and to analyse diagnostic performance of two-dimensional shear wave elastography (2D-SWE) for the detection of hepatic involvement. METHODS Patients with CF treated and followed at our centre were evaluated prospectively. All patients underwent liver tissue stiffness (TS) measurements by 2D-SWE, in addition to routine clinical assessments, laboratory work-up and abdominal ultrasound imaging. Data from patients with CF were compared with healthy control subjects. RESULTS This study included 39 patients with CF and 37 healthy controls. Patients had a mean body weight of 29.9 (16.6-55) kg, mean age of 9 (5-17) years, mean height of 130 (107-172) cm and a mean body mass index of 16.1 (12.8-21.4) kg/m2 . Average SWE values of the liver were 1.02 (0.70-1.60) m/s in patients with CF (n = 39) and 0.89 (0.60-1.35) m/s in healthy controls (n = 37). Cystic fibrosis patients had significantly increased tissue stifness by liver elastography compared to controls (P = 0.005). CONCLUSION Parenchymal liver changes may occur early in cystic fibrosis, which cannot be detected by conventional ultrasonography but may be demonstrated by 2D-SWE. Based on this cross-sectional study, 2D-SWE may be a promising, simple and non-invasive modality for objective monitoring of patients with cystic fibrosis who require lifelong follow-up, by providing numerical data for tissue stiffness early in the disease.
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Affiliation(s)
- Sibel Yavuz
- Department of Pediatric Gastroenterology, Cukurova University Medical Faculty, Adana, Turkey
| | - Ferhat C Pişkin
- Department of Radiology, Cukurova University Medical Faculty, Adana, Turkey
| | - Cemil Oktay
- Department of Radiology, Adıyaman University Education and Research Hospital, Adıyaman, Turkey
| | - Gökhan Tümgör
- Department of Pediatric Gastroenterology, Cukurova University Medical Faculty, Adana, Turkey
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14
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Scott J, Jones AM, Piper Hanley K, Athwal VS. Review article: epidemiology, pathogenesis and management of liver disease in adults with cystic fibrosis. Aliment Pharmacol Ther 2022; 55:389-400. [PMID: 35048397 DOI: 10.1111/apt.16749] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/18/2021] [Accepted: 12/13/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cystic fibrosis-related liver disease (CFLD) is the leading cause of death in cystic fibrosis (CF), after pulmonary disease. To improve identification and management of this condition requires an understanding of the underlying disease mechanism. AIMS This review summarises the current understanding of CFLD epidemiology, pathology, diagnosis and management. METHODS Relevant reports on cystic fibrosis liver disease were identified using a literature search and summarised. RESULTS CFLD is a heterogeneous condition with several different co-existent pathologies, including environmental and genetic factors. Incidence of clinically significant CFLD continues at a linear rate into early adulthood and has been described in up to 25% of CF patients. Diagnosis strategies lack precision and patient risk stratification needs to look beyond Childs-Pugh scoring. Efficacious therapies are lacking and, at present, newer modulator therapies lack data in CFLD and carry an increased risk of hepatotoxicity. Outcomes of liver transplant are comparable to non-CF transplant indications. CONCLUSIONS The incidence of CFLD increases with age and hence is increasingly important to adult patients with CF. Effective therapies are lacking. For progress to be made a better understanding of pathogenesis and disease detection are required.
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Affiliation(s)
- Jennifer Scott
- Division of Gastroenterology and Hepatology, Manchester University NHS Foundation Trust, Manchester, UK
- Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Andrew M Jones
- Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
- Manchester Adult Cystic Fibrosis Centre, Manchester University NHS Foundation Trust UK, Manchester, UK
| | - Karen Piper Hanley
- Division of Gastroenterology and Hepatology, Manchester University NHS Foundation Trust, Manchester, UK
- Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Varinder S Athwal
- Division of Gastroenterology and Hepatology, Manchester University NHS Foundation Trust, Manchester, UK
- Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
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15
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Cystic fibrosis-related liver disease: Clinical presentations, diagnostic and monitoring approaches in the era of CFTR modulator therapies. J Hepatol 2022; 76:420-434. [PMID: 34678405 DOI: 10.1016/j.jhep.2021.09.042] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/09/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022]
Abstract
Cystic fibrosis (CF) is the most common autosomal recessive disease in the Caucasian population. Cystic fibrosis-related liver disease (CFLD) is defined as the pathogenesis related to the underlying CFTR defect in biliary epithelial cells. CFLD needs to be distinguished from other liver manifestations that may not have any pathological significance. The clinical/histological presentation and severity of CFLD vary. The main histological presentation of CFLD is focal biliary fibrosis, which is usually asymptomatic. Portal hypertension develops in a minority of cases (about 10%) and may require specific management including liver transplantation for end-stage liver disease. Portal hypertension is usually the result of the progression of focal biliary fibrosis to multilobular cirrhosis during childhood. Nevertheless, non-cirrhotic portal hypertension as a result of porto-sinusoidal vascular disease is now identified increasingly more frequently, mainly in young adults. To evaluate the effect of new CFTR modulator therapies on the liver, the spectrum of hepatobiliary involvement must first be precisely classified. This paper discusses the phenotypic features of CFLD, its underlying physiopathology and relevant diagnostic and follow-up approaches, with a special focus on imaging.
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16
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Calvopina DA, Lewindon PJ, Ramm LE, Noble C, Hartel GF, Leung DH, Ramm GA. Gamma-glutamyl transpeptidase-to-platelet ratio as a biomarker of liver disease and hepatic fibrosis severity in paediatric Cystic Fibrosis. J Cyst Fibros 2021; 21:236-242. [PMID: 34953741 DOI: 10.1016/j.jcf.2021.10.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 10/17/2021] [Accepted: 10/19/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Cystic fibrosis (CF)-associated liver disease (CFLD) causes significant morbidity and mortality in children with CF. Diagnosis of liver disease prior to development of cirrhosis or portal hypertension (PHT) is challenging. While imaging modalities using Elastography show great promise they are still not widely available to all clinicians. This study investigated gamma-glutamyl transpeptidase-to-platelet ratio (GPR) as a non-invasive biomarker to detect liver disease and stage fibrosis severity in children with CF. METHODS 237 children were enroled including 76 with CFLD and 161 with CF and no detectable liver disease (CFnoLD). CFLD was diagnosed using standard clinical, biochemical and imaging practice guidelines. Hepatic fibrosis was staged on liver biopsies available from 54 children with CFLD. Serum liver biochemistry was used to calculate GPR (median, [IQR]) and receiver operating characteristics (ROC) analysis assessed utility to detect liver disease and stage fibrosis severity. RESULTS GPR was significantly increased in CFLD versus CFnoLD (0.33 [0.19-0.96] vs. 0.15 [0.11-0.21], P<0.0001). GPR demonstrated good diagnostic utility for detecting CFLD with an area under the curve (AUC) of 0.81 (95% confidence Interval [CI] [0.75-0.87]; P<0.0001), with sensitivity of 74% and specificity of 73%, using a cut-off of 0.20. GPR increased with increasing hepatic fibrosis stage. GPR discriminated both moderate-advanced (F2-F4) fibrosis vs. F0-F1 (AUC=0.82; 95%CI [0.71-0.94]; P<0.0001) and advanced (F3-F4) fibrosis vs. F0-F2 (AUC=0.77; 95%CI [0.64-0.90]; P = 0.004), with a cut-off 0.32 and 0.61, respectively. An elevated GPR of >0.84 was predictive of PHT at diagnosis of CFLD (AUC=0.81; 95%CI [0.67-0.95]; P = 0.0003). CONCLUSIONS GPR demonstrates good diagnostic utility for assessing the presence of liver disease, PHT and hepatic fibrosis severity in children with CF. These findings will aid in better identification of patients at risk for CF-related liver involvement and the potential for more targeted and timely follow-up and treatment.
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Affiliation(s)
- Diego A Calvopina
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, 300 Herston Rd, Herston, QLD 4006, Australia.
| | - Peter J Lewindon
- Department of Gastroenterology and Hepatology, Queensland Children's Hospital, 501 Stanley St, South Brisbane; Faculty of Medicine, The University of Queensland, Brisbane, QLD 4006, Australia.
| | - Louise E Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, 300 Herston Rd, Herston, QLD 4006, Australia.
| | - Charlton Noble
- Department of Gastroenterology and Hepatology, Queensland Children's Hospital, 501 Stanley St, South Brisbane.
| | - Gunter F Hartel
- QIMR Berghofer Statistics Unit, QIMR Berghofer Medical Research Institute, 300 Herston Rd, Herston, QLD 4006, Australia.
| | - Daniel H Leung
- Division of Pediatric Gastroenterology, Hepatology, Nutrition, Baylor College of Medicine, Houston, TX, USA; Texas Children's Liver Center, Houston, USA.
| | - Grant A Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, 300 Herston Rd, Herston, QLD 4006, Australia; Faculty of Medicine, The University of Queensland, Brisbane, QLD 4006, Australia.
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17
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Advanced but not mild liver disease is a predictor of decreased survival in children with cystic fibrosis, with far greater impact in females: A 27-year real-life cohort study. J Cyst Fibros 2021; 21:230-235. [PMID: 34949555 DOI: 10.1016/j.jcf.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/19/2021] [Accepted: 11/23/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Improved survival of children with CF has increased our need to understand the relevance of cystic fibrosis-associated liver disease (CFLD). We assessed the impact of liver disease and disease severity on the survival of children with cystic fibrosis. METHODS A real life, single center cohort study with 27 years follow up was conducted. Mild CFLD was diagnosed as children with abnormal serum liver function tests and abnormal ultrasound. Advanced CFLD was established by detection of cirrhosis or portal hypertension. A directed acyclic graph, Kaplan-Meier (KM) and Cox regression analysis were used to model survival. RESULTS 290 patients were enrolled, 48 (16.5%) had mild CFLD and 55 (19%) had advanced CFLD. Ten children with advanced CFLD and 1 with mild CFLD died. Based on the KM analysis, the mean (SE) overall survival age of all CF children was 29.1 years (0.50). The mean (SE) survival among females with advanced CFLD was 24.7 years (1.58) compared to 30.4 years (0.66) for females without advanced CFLD (p = 0.0027). Advanced CFLD was a predictor of decreased survival when adjusted for sex and diabetes (HR 2.54, 95%CI 1.05-6.15, p = 0.039). Mild CFLD was not associated with decreased survival. The effect of advanced CFLD on survival was mainly borne by females (HR = 6.37, 95%CI 1.62-25.06 vs. males, HR = 1.00, 95%CI 0.25-4.01). CONCLUSION Advanced but not mild CFLD was associated with an increased risk of death when adjusted for sex and diabetes, and resulted in premature death in females with cystic fibrosis by approximately 6 years.
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18
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Valamparampil JJ, Gupte GL. Cystic fibrosis associated liver disease in children. World J Hepatol 2021; 13:1727-1742. [PMID: 34904041 PMCID: PMC8637674 DOI: 10.4254/wjh.v13.i11.1727] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/19/2021] [Accepted: 09/17/2021] [Indexed: 02/06/2023] Open
Abstract
Cystic fibrosis (CF) is an autosomal recessive disorder caused by mutations in the CF transmembrane conductance regulator gene. CF liver disease develops in 5%-10% of patients with CF and is the third leading cause of death among patients with CF after pulmonary disease or lung transplant complications. We review the pathogenesis, clinical presentations, complications, diagnostic evaluation, effect of medical therapies especially CF transmembrane conductance regulator modulators and liver transplantation in CF associated liver disease.
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Affiliation(s)
| | - Girish L Gupte
- Liver Unit, Birmingham Children’s Hospital, Birmingham B4 6NH, United Kingdom
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19
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Abstract
PURPOSE OF REVIEW Liver disease (CFLD) as a complication of cystic fibrosis is recognized as a more severe disease phenotype in both children and adults. We review recent advances in understanding the disease mechanism and consider the implications of new strategies for the diagnosis and management of cystic fibrosis in those with evidence of clinically significant liver disease. RECENT FINDINGS Evidence suggests that the prevalence of CFLD has not declined with the introduction of newborn screening. Furthermore, children with CFLD, who have been diagnosed with cystic fibrosis following newborn screening continue to have a much higher mortality rate compared with those with no liver disease. There is further data suggesting noncirrhotic obliterative portal venopathy as the predominant pathological mechanism in the majority of children and young adults receiving a liver transplantation. Little progress has been made in developing an accurate noninvasive test for early diagnosis or monitoring disease progression in CFLD. The benefit of new modulator therapies is not well understood in those with established CFLD, whereas the risk of hepatotoxicity as a complication of treatment must be carefully monitored. SUMMARY Better understanding of the pathophysiology of CFLD would allow a standardized approach to diagnosis, with the potential to improve outcomes for those with CFLD.
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20
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Bell PT, Carew A, Fiene A, Divithotawela C, Stuart KA, Hodgkinson P, Chambers DC, Hopkins PM. Combined Heart-Lung-Liver Transplantation for Patients With Cystic Fibrosis: The Australian Experience. Transplant Proc 2021; 53:2382-2389. [PMID: 34412912 DOI: 10.1016/j.transproceed.2021.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 07/19/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Combined multivisceral transplantation has emerged as a therapeutic option for a select patient cohort; however, clinical decision-making remains complex and controversial. The aim of this study was to examine patient characteristics, operative complications, and long-term outcomes of all patients who have undergone combined heart-lung-liver transplantation (HLLTx) in Australia. METHODS In this study, we performed a retrospective analysis of all adult patients who have undergone combined HLLTx in Australia to date. Recipient clinical characteristics, waitlist, and transplant outcomes are described. RESULTS Eight adult patients have received HLLTx at a single Australian transplant center. Recipients of HLLTx have typically been young (median age, 30.1 years; range, 24-37), underweight (median body mass index, 19.8 kg/m2; range, 16.2-30.4) patients with cystic fibrosis (n = 8, 100%) with severe airflow obstruction (median forced expiratory volume in the first second of expiration, 24% predicted; range, 17%-48%) accompanied by liver cirrhosis confirmed on histopathology (n = 8, 100%). Despite relative preservation of synthetic function and low model for end-stage liver disease scores (median, 8; range, 6-17), all recipients had complications of portal hypertension prior to transplantation, with many patients having suffered life-threatening variceal hemorrhage. In this cohort, HLLTx was associated with overall posttransplant survival of 87.5% at 30 days, 71.4% at 1 year, and 42.9% at 5 years. Listing for combined HLLTx was associated with prolonged waitlist times relative to bilateral sequential single-lung transplantation (median 556 vs 56 days, respectively), however waitlist mortality and/or delisting was comparable between groups. CONCLUSIONS Taken together, these findings highlight the opportunities and challenges facing combined (heart-) lung and liver transplantation in patients with multiorgan failure.
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Affiliation(s)
- P T Bell
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - A Carew
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - A Fiene
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia
| | - C Divithotawela
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia
| | - K A Stuart
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Australia
| | - P Hodgkinson
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Australia
| | - D C Chambers
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - P M Hopkins
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia.
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Sasame A, Stokes D, Bourke B, Connolly L, Fitzpatrick E, Rowland M. The impact of liver disease on mortality in cystic fibrosis-A systematic review. J Cyst Fibros 2021; 21:202-211. [PMID: 34380590 DOI: 10.1016/j.jcf.2021.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/12/2021] [Accepted: 07/24/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND There is conflicting evidence on the impact of liver disease (CFLD) on life expectancy in CF. Therefore the aim of this systematic review was to evaluate the impact of liver disease (CFLD) on mortality in CF. METHODS The protocol was published at (https://hrbopenresearch.org/articles/3-44/v3) using PRISPMA-P guidelines and registered in Prospero 2020 (CRD42020182885). Three databases were searched for publications (1938-2020) where the outcome was all-cause mortality (defined as death and transplantation) or CF-specific mortality in participants with CFLD. Studies with and without a comparator group were included. Studies were divided into 2 groups based on the definition of CFLD: Group 1 used 2 categories of liver disease (i) liver disease with portal hypertension (PH) (ii) non-specific abnormalities which did not meet the criteria for PH, Group 2 studies only included participants with PH. RESULTS All 14 eligible studies were observational, with a moderate-high risk of bias, Six of the 14 studies directly compared mortality between those with CFLD and those with no liver disease, and 5/6 demonstrated that those with CFLD had at least 3 time the risk of death compared to those with no liver disease. Pulmonary complications were the primary cause of death. CONCLUSION This SR demonstrates that liver disease shortens life expectancy in CF, and that pulmonary complications are the primary cause of death in those with CFLD. There has been no improvement in survival for persons with CFLD despite significant improvements in life expectancy for persons with CF who have no evidence of liver disease.
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Affiliation(s)
- Ao Sasame
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland
| | - Diarmuid Stokes
- UCD Library, University College Dublin, Belfield, Dublin 4, Ireland
| | - Billy Bourke
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland; Children's Health Ireland at Crumlin, Crumlin, Dublin 12, Ireland; King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Lucy Connolly
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland
| | - Emer Fitzpatrick
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland; Children's Health Ireland at Crumlin, Crumlin, Dublin 12, Ireland; King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Marion Rowland
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland.
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Ye W, Leung DH, Molleston JP, Ling SC, Murray KF, Nicholas JL, Huang S, Karmazyn BW, Harned RK, Masand P, Alazraki AL, Navarro OM, Otto RK, Palermo JJ, Towbin AJ, Alonso EM, Karnsakul WW, Jane Schwarzenberg S, Seidel GF, Siegel M, Magee JC, Narkewicz MR, Jay Freeman A. Association Between Transient Elastography and Controlled Attenuated Parameter and Liver Ultrasound in Children With Cystic Fibrosis. Hepatol Commun 2021; 5:1362-1372. [PMID: 34430781 PMCID: PMC8369935 DOI: 10.1002/hep4.1719] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/14/2021] [Accepted: 03/01/2021] [Indexed: 02/04/2023] Open
Abstract
Methods to identify children with cystic fibrosis (CF) at risk for development of advanced liver disease are lacking. We aim to determine the association between liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE) with research ultrasound (US) patterns and conventional hepatic markers as a potential means to follow liver disease progression in children with CF. ELASTIC (Longitudinal Assessment of Transient Elastography in CF) is a nested cohort of 141 patients, ages 7-21, enrolled in the Prediction by US of Risk of Hepatic Cirrhosis in CF (PUSH) Study. We studied the association between LSM with research-grade US patterns (normal [NL], heterogeneous [HTG], homogeneous [HMG], or nodular [NOD]) and conventional hepatic markers. In a subgroup (n = 79), the association between controlled attenuation parameter (CAP) and US pattern was explored. Among 133 subjects undergoing VCTE, NOD participants (n = 26) had a significantly higher median (interquartile range) LSM of 9.1 kPa (6.3, 15.8) versus NL (n = 72, 5.1 kPa [4.2, 7.0]; P < 0.0001), HMG (n = 17, 5.9 kPa [5.2, 7.8]; P = 0.0013), and HTG (n = 18, 6.1 kPa [4.7, 7.0]; P = 0.0008) participants. HMG participants (n = 14) had a significantly higher mean CAP (SD) (270.5 dB/m [61.1]) compared with NL (n = 40, 218.8 dB/m [46.5]; P = 0.0027), HTG (n = 10, 218.1 dB/m [60.7]; P = 0.044), and NOD (n = 15, 222.7 dB/m [56.4]; P = 0.041) participants. LSM had a negative correlation with platelet count (rs = - 0.28, P = 0.0071) and positive correlation with aspartate aminotransferase-to-platelet ratio index (rs = 0.38, P = 0.0002), Fibrosis-4 index (rs = 0.36, P = 0.0007), gamma-glutamyltransferase (GGT; rs = 0.35, P = 0.0017), GGT-to-platelet ratio (rs = 0.35, P = 0.003), and US spleen size z-score (rs = 0.27, P = 0.0073). Conclusion: VCTE is associated with US patterns and conventional markers in patients with liver disease with CF.
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Affiliation(s)
- Wen Ye
- Department of BiostatisticsUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and NutritionDepartment of PediatricsTexas Children's HospitalBaylor College of MedicineHoustonTXUSA
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology and NutritionRiley Hospital for Children at IU HealthIndiana University School of MedicineIndianapolisINUSA
| | - Simon C Ling
- The Hospital for Sick ChildrenDepartment of PediatricsUniversity of TorontoTorontoONCanada
| | - Karen F Murray
- Division of Gastroenterology and HepatologyUniversity of Washington and Seattle Children's HospitalSeattleWAUSA
| | - Jennifer L Nicholas
- Mallinckrodt Institute of RadiologyWashington University School of MedicineSt. LouisMOUSA
| | - Suiyuan Huang
- Department of BiostatisticsUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | - Boaz W Karmazyn
- Pediatric RadiologyRiley Hospital for Children at IU HealthIndiana University School of MedicineIndianapolisINUSA
| | - Roger K Harned
- Division of Pediatric RadiologyChildren's Hospital Colorado and University of Colorado School of MedicineAuroraCOUSA
| | - Prakash Masand
- Division of RadiologyTexas Children's HospitalHoustonTXUSA
| | - Adina L Alazraki
- Department of RadiologyEmory University School of Medicine and Children's Healthcare of AtlantaAtlantaGAUSA
| | - Oscar M Navarro
- Department of Medical ImagingUniversity of TorontoTorontoONCanada.,Department of Diagnostic ImagingThe Hospital for Sick ChildrenTorontoONCanada
| | - Randolph K Otto
- Department of RadiologyUniversity of Washington and Seattle Children's HospitalSeattleWAUSA
| | - Joseph J Palermo
- Division of Pediatric Gastroenterology, Hepatology and NutritionCincinnati Children's Hospital Medical CenterCincinnatiOHUSA.,Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Alexander J Towbin
- Department of RadiologyCincinnati Children's Hospital Medical CenterCincinnatiOHUSA.,Department of RadiologyUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Estella M Alonso
- Division of Pediatric Gastroenterology, Hepatology and NutritionAnn & Robert H. Lurie Children's HospitalChicagoILUSA
| | - Wikrom W Karnsakul
- Division of Pediatric Gastroenterology, Hepatology and NutritionJohn Hopkins School of MedicineBaltimoreMDUSA
| | | | - Glenn F Seidel
- Pediatric RadiologyLucile Packard Children's HospitalPalo AltoCAUSA
| | - Marilyn Siegel
- Mallinckrodt Institute of RadiologyWashington University School of MedicineSt. LouisMOUSA
| | - John C Magee
- Department of SurgeryUniversity of Michigan Medical SchoolAnn ArborMIUSA
| | - Michael R Narkewicz
- Digestive Health InstituteChildren's Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and NutritionDepartment of PediatricsUniversity of Colorado School of MedicineAuroraCOUSA
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and NutritionEmory University School of Medicine/Children's Healthcare of AtlantaAtlantaGAUSA
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23
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Colombo C, Alicandro G, Oliver M, Lewindon PJ, Ramm GA, Ooi CY, Alghisi F, Kashirskaya N, Kondratyeva E, Corti F, Padoan R, Asherova I, Evans H, de Monestrol I, Strandvik B, Lindblad A. Ursodeoxycholic acid and liver disease associated with cystic fibrosis: A multicenter cohort study. J Cyst Fibros 2021; 21:220-226. [PMID: 33814323 DOI: 10.1016/j.jcf.2021.03.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/10/2021] [Accepted: 03/15/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The efficacy and safety of ursodeoxycholic acid (UDCA) for the treatment of liver disease associated with cystic fibrosis (CF) are under discussion, and clinical practice varies among centers. The study aimed at evaluating if the incidence of severe liver disease differs between CF centers routinely prescribing or not prescribing UDCA. METHODS We carried out a retrospective multicenter cohort study including 1591 CF patients (1192 patients from UDCA-prescribing centers and 399 from non-prescribing centers) born between 1990 and 2007 and followed from birth up to 31 December 2016. We computed the crude cumulative incidence (CCI) of portal hypertension (PH) at the age of 20 years in the two groups and estimated the subdistribution hazard ratio (HR) through a Fine and Gray model. RESULTS Over the observation period, 114 patients developed PH: 90 (7.6%) patients followed-up in UDCA prescribing centers and 24 (6.0%) in non-prescribing centers. The CCI of PH at 20 years was 10.1% (95% CI: 7.9-12.3) in UDCA-prescribing and 7.7% (95% CI: 4.6-10.7) in non-prescribing centers. The HR among patients followed in prescribing centers indicated no significant difference in the rate of PH either in the unadjusted model (HR: 1.21, 95% CI: 0.69-2.11) or in the model adjusted for pancreatic insufficiency (HR: 1.28, 95% CI: 0.77-2.12). CONCLUSIONS CF patients followed-up in UDCA prescribing centers did not show a lower incidence of PH as compared to those followed in centers not prescribing UDCA. These results question the utility of UDCA in reducing the occurrence of severe liver disease in CF.
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Affiliation(s)
- Carla Colombo
- IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy.
| | - Gianfranco Alicandro
- Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Mark Oliver
- Royal Children's Hospital, Melbourne, Australia
| | | | - Grant A Ramm
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Chee Y Ooi
- Sydney Children's Hospital & School of Women's and Children's Health, Medicine, University of New South Wales, Sydney, Australia
| | | | - Nataliya Kashirskaya
- Federal State Budgetary Scientific Institution «Research Centre for Medical Genetics», Moscow, Russia
| | - Elena Kondratyeva
- Federal State Budgetary Scientific Institution «Research Centre for Medical Genetics», Moscow, Russia
| | - Fabiola Corti
- IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | - Helen Evans
- Starship Children's Health, Auckland, New Zealand
| | | | - Birgitta Strandvik
- Department of Bioscience and Nutrition, Karolinska Institutet, Stockholm, Sweden
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24
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De Palma FDE, Raia V, Kroemer G, Maiuri MC. The Multifaceted Roles of MicroRNAs in Cystic Fibrosis. Diagnostics (Basel) 2020; 10:E1102. [PMID: 33348555 PMCID: PMC7765910 DOI: 10.3390/diagnostics10121102] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/11/2022] Open
Abstract
Cystic fibrosis (CF) is a lifelong disorder affecting 1 in 3500 live births worldwide. It is a monogenetic autosomal recessive disease caused by loss-of-function mutations in the gene encoding the chloride channel cystic fibrosis transmembrane conductance regulator (CFTR), the impairment of which leads to ionic disequilibria in exocrine organs. This translates into a chronic multisystemic disease characterized by airway obstruction, respiratory infections, and pancreatic insufficiency as well as hepatobiliary and gastrointestinal dysfunction. Molecular characterization of the mutational heterogeneity of CFTR (affected by more than 2000 variants) improved the understanding and management of CF. However, these CFTR variants are linked to different clinical manifestations and phenotypes, and they affect response to treatments. Expanding evidence suggests that multisystemic disease affects CF pathology via impairing either CFTR or proteins regulated by CFTR. Thus, altering the expression of miRNAs in vivo could constitute an appealing strategy for developing new CF therapies. In this review, we will first describe the pathophysiology and clinical management of CF. Then, we will summarize the current knowledge on altered miRNAs in CF patients, with a focus on the miRNAs involved in the deregulation of CFTR and in the modulation of inflammation. We will highlight recent findings on the potential utility of measuring circulating miRNAs in CF as diagnostic, prognostic, and predictive biomarkers. Finally, we will provide an overview on potential miRNA-based therapeutic approaches.
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Affiliation(s)
- Fatima Domenica Elisa De Palma
- Equipe 11 Labellisée Ligue Contre le Cancer, Centre de Recherche des Cordeliers, INSERM UMRS 1138, Sorbonne Université, Université of Paris, 75006 Paris, France;
- Metabolomics and Cell Biology Platforms, Gustave Roussy Comprehensive Cancer Institute, 94805 Villejuif, France
- CEINGE-Biotecnologie Avanzate, 80145 Naples, Italy
| | - Valeria Raia
- Pediatric Unit, Department of Translational Medical Sciences, Regional Cystic Fibrosis Center, Federico II University Naples, 80131 Naples, Italy;
| | - Guido Kroemer
- Equipe 11 Labellisée Ligue Contre le Cancer, Centre de Recherche des Cordeliers, INSERM UMRS 1138, Sorbonne Université, Université of Paris, 75006 Paris, France;
- Metabolomics and Cell Biology Platforms, Gustave Roussy Comprehensive Cancer Institute, 94805 Villejuif, France
- Suzhou Institute for Systems Medicine, Chinese Academy of Sciences, Suzhou 215123, China
- Karolinska Institutet, Department of Women’s and Children’s Health, 17176 Stockholm, Sweden
- Pôle de Biologie, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
- Institut Universitaire de France, 75005 Paris, France
| | - Maria Chiara Maiuri
- Equipe 11 Labellisée Ligue Contre le Cancer, Centre de Recherche des Cordeliers, INSERM UMRS 1138, Sorbonne Université, Université of Paris, 75006 Paris, France;
- Metabolomics and Cell Biology Platforms, Gustave Roussy Comprehensive Cancer Institute, 94805 Villejuif, France
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25
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Galante G, Freeman AJ. Gastrointestinal, Pancreatic, and Hepatic Manifestations of Cystic Fibrosis in the Newborn. Neoreviews 2020; 20:e12-e24. [PMID: 31261070 DOI: 10.1542/neo.20-1-e12] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Gastrointestinal, pancreatic, and hepatic signs and symptoms represent the most common presentation of early disease among patients with cystic fibrosis and may be the initial indication of disease. Regardless of whether cystic fibrosis is diagnosed early by newborn screening or later by clinical course, the impact of gastrointestinal, pancreatic, and hepatic manifestations on early life is nearly ubiquitous. Conditions strongly linked with cystic fibrosis, such as meconium ileus and pancreatic insufficiency, must be recognized and treated early to optimize both short- and long-term care. Similarly, less specific conditions such as reflux, poor weight gain, and cholestasis are frequently encountered in infants with cystic fibrosis. In this population, these conditions may present unique challenges in which early interventions may have significant influence on both short- and long-term morbidity and mortality outcomes.
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26
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Diagnosis of Acute Rejection of Liver Grafts in Young Children Using Acoustic Radiation Force Impulse Imaging. AJR Am J Roentgenol 2020; 215:1229-1237. [PMID: 32877250 DOI: 10.2214/ajr.19.22057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE. Frequency of acute rejection (AR) after pediatric liver transplant remains high despite progress in immunosuppression. Liver biopsy (LB) is the reference standard for the diagnosis of AR despite its potential for morbidity. The purpose of our study was to evaluate the ability of acoustic radiation force impulse (ARFI) imaging to distinguish AR from other causes of short- and medium-term liver dysfunction and to identify liver transplant cases with normal liver function. MATERIALS AND METHODS. ARFI imaging was used to evaluate shear wave velocity (SWV) after liver transplant in young children. All pediatric liver grafts that had LB and ARFI examination between January 2014 and December 2017 were included in this retrospective study. Results of LB were compared with those of SWV. Collected data included age at biopsy and transplant, sex, weight, height, body mass index, interval between liver transplant and shear wave elastography and LB, kind of graft, type of donor, and diagnosis at transplant. ROC curve analysis was performed to assess the diagnostic performance of SWV. Optimal cutoff of SWV using ARFI imaging in predicting AR was identified using the Youden index. RESULTS. Statistical analysis was performed on 54 children; six of the original 60 were excluded because of confounding alterations or changes in outcome. Median SWV was higher in patients with AR (2.03 m/s; interquartile range [IQR], 1.80-2.45 m/s) compared with those with idiopathic hepatitis (1.33 m/s; IQR, 1.12-1.53 m/s), portal hypertension (1.42 m/s; IQR, 1.32-1.72 m/s), cholangitis (1.56 m/s; IQR, 1.07-1.62 m/s) or normal liver function (1.23 m/s; IQR 1.12-1.29 m/s) at protocol biopsies (all comparisons, p < 0.01). SWV higher than 1.73 m/s was predictive for AR (AUC, 0.966). SWV also showed good diagnostic accuracy in normal liver function (AUC, 0.791). ARFI imaging was not predictive for hepatitis (AUC, 0.402), portal hypertension (AUC, 0.556), or cholangitis (AUC, 0.420). CONCLUSION. ARFI imaging could be routinely used in place of LB in pediatric patients with liver dysfunction after liver transplant, restricting indication and risks of biopsy to selected cases.
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27
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Calvopina DA, Noble C, Weis A, Hartel GF, Ramm LE, Balouch F, Fernandez-Rojo MA, Coleman MA, Lewindon PJ, Ramm GA. Supersonic shear-wave elastography and APRI for the detection and staging of liver disease in pediatric cystic fibrosis. J Cyst Fibros 2020; 19:449-454. [DOI: 10.1016/j.jcf.2019.06.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/28/2019] [Accepted: 06/30/2019] [Indexed: 12/18/2022]
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28
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Hepatobiliary Involvement in Cystic Fibrosis. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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29
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Lewindon PJ, Puertolas-Lopez MV, Ramm LE, Noble C, Pereira TN, Wixey JA, Hartel GF, Calvopina DA, Leung DH, Ramm GA. Accuracy of Transient Elastography Data Combined With APRI in Detection and Staging of Liver Disease in Pediatric Patients With Cystic Fibrosis. Clin Gastroenterol Hepatol 2019; 17:2561-2569.e5. [PMID: 30880274 DOI: 10.1016/j.cgh.2019.03.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 02/24/2019] [Accepted: 03/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Liver disease develops in 15%-72% of patients with cystic fibrosis, and 5%-10% develop cirrhosis or portal hypertension, usually during childhood. Transient elastography (TE) is a noninvasive method to measure liver stiffness. We aimed to validate its accuracy in detection of liver disease and assessment of fibrosis in children with cystic fibrosis. METHODS We performed a cross-sectional study to evaluate the accuracy of TE in analysis of liver disease in 160 consecutive children who presented with cystic fibrosis (9.0 ± 0.4 years old, 53% male) at a tertiary referral pediatric center in Australia, from 2011 through 2016. Patients were classified as having cystic fibrosis-associated liver disease (CFLD) or cystic fibrosis without liver disease (CFnoLD) based on clinical, biochemical, and imaging features. Fibrosis severity was determined from histologic analysis of dual-pass liver biopsies from children with CFLD, as the reference standard. Data from healthy children without cystic fibrosis (n = 64, controls) were obtained from a separate study. Liver stiffness measurements (LSMs) were made by Fibroscan analysis, using the inter-quartile range/median ≤30% of 10 valid measurements. Children with macronodularity or portal hypertension with heterogeneous changes on ultrasound without available biopsy were assigned to the category of stage F3-F4 fibrosis. RESULTS LSM was made reliably in 86% of children; accuracy increased with age. LSMs were significantly higher in children with CFLD (10.7 ± 2.4 kPa, n = 33) than with CFnoLD (4.6 ± 0.1 kPa, n = 105) (P < .0001) or controls (4.1 ± 0.1kPa) (P < .0001); LSMs were higher in children with CFnoLD than controls (P < .05). At a cut-off value of 5.55kPa, LSM identified children with CFLD with an area under the receiver operating characteristic (AUROC) curve of 0.82, 70% sensitivity, and 82% specificity (P < .0001). Classification and regression tree models that combined LSM and aspartate aminotransferase to platelet ratio index (APRI) identified children with CFLD with an AUROC curve of 0.89, 87% sensitivity, and 74% specificity (odds ratio, 18.6). LSMs correlated with fibrosis stage in patients with CFLD (r = 0.67, P = .0001). A cut-off value of 8.7kPa differentiated patients with stage F3-F4 fibrosis from patients with stage F1-F2 fibrosis (AUROC, 0.87; 75% sensitivity; 100% specificity, P=.0002). The combination of LSMs and APRI improved the differentiation of patients with F3-F4 fibrosis vs F1-F2 fibrosis (AUROC, 0.92; 83% sensitivity; and 100% specificity (P < .01). CONCLUSIONS LSMs made by TE accurately detect liver disease in children with cystic fibrosis; diagnostic accuracy increases when LSMs are combined with APRI. LSMs also differentiate between children with cystic fibrosis with mild-moderate fibrosis vs advanced fibrosis.
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Affiliation(s)
- Peter J Lewindon
- Department of Gastroenterology, Hepatology and Liver Transplant, Lady Cilento Children's Hospital, Brisbane, Australia
| | - Mora V Puertolas-Lopez
- Holtz Children's Hospital, University of Miami/Jackson Memorial Medical Center, Miami, Florida
| | - Louise E Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Charlton Noble
- Department of Gastroenterology, Hepatology and Liver Transplant, Lady Cilento Children's Hospital, Brisbane, Australia
| | - Tamara N Pereira
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Julie A Wixey
- University of Queensland Centre for Clinical Research, Brisbane, Australia
| | - Gunter F Hartel
- Statistics Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Diego A Calvopina
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Daniel H Leung
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Division of Pediatric Gastroenterology, Hepatology, Nutrition, Texas Children's Hospital, Houston, Texas
| | - Grant A Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia.
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30
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Hercun J, Alvarez F, Vincent C, Bilodeau M. Cystic fibrosis liver disease: A condition in need of structured transition and continuity of care. CANADIAN LIVER JOURNAL 2019; 2:71-83. [PMID: 35990223 PMCID: PMC9202747 DOI: 10.3138/canlivj-2018-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 09/10/2018] [Indexed: 08/05/2023]
Abstract
Liver disease affects one-third of patients with cystic fibrosis (CF) and it is one of the major causes of morbidity and mortality in these patients. Historically considered a disease of childhood, its impact is now seen more often in adulthood. The heterogeneous pattern of CF liver disease and its rapid progression to cirrhosis remain a diagnostic challenge and new questions pertaining to the nature of liver involvement have recently been raised. Non-invasive measures to stratify the severity of liver involvement are increasingly used to predict clinical outcomes. A single treatment, ursodeoxycholic acid, has been used to slow progression of liver disease while recent advances in the field of CF treatments are promising. Management of portal hypertension remains challenging but outcomes after liver transplantation are encouraging. While many questions remain unanswered, a growing number of CF patients reach adulthood and will require care for CF liver disease.
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Affiliation(s)
- Julian Hercun
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
| | - Fernando Alvarez
- Gastroenterology, Hepatology and Nutrition Division, CHU Sainte-Justine, Montréal, Québec
| | - Catherine Vincent
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
| | - Marc Bilodeau
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
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31
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Boëlle P, Debray D, Guillot L, Clement A, Corvol H. Cystic Fibrosis Liver Disease: Outcomes and Risk Factors in a Large Cohort of French Patients. Hepatology 2019; 69:1648-1656. [PMID: 30058245 PMCID: PMC6519059 DOI: 10.1002/hep.30148] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 06/09/2018] [Indexed: 12/12/2022]
Abstract
Cystic fibrosis (CF)-related liver disease (CFLD) is a common symptom in patients with CF. However, its prevalence, risk factors, and evolution are unclear. We analyzed a large database of patients with CF to investigate the incidence of CFLD, its related risk factors, and the use and effect of ursodeoxycholic acid (UDCA) treatment. We retrospectively analyzed 3,328 CF patients with pancreatic insufficiency born after 1985 and recruited into the French CF Modifier Gene Study since 2004. We determined liver status, age at CFLD and severe CFLD onset, sex, CFTR genotype, history of meconium ileus, treatment with UDCA, and respiratory and nutritional status. The incidence of CFLD increased by approximately 1% every year, reaching 32.2% by age 25. The incidence of severe CFLD increased only after the age of 5, reaching 10% by age 30. Risk factors for CFLD and severe CFLD were male sex, CFTR F508del homozygosity, and history of meconium ileus. Increasingly precocious initiation of UDCA treatment did not change the incidence of severe CFLD. Finally, patients with severe CFLD had worse lung function and nutritional status than other CF patients. Conclusion: CFLD occurs not only during childhood but also later in the lifetime of patients with CF; male sex, CFTR F508del homozygosity, and history of meconium ileus are independent risk factors for CFLD development; earlier use of UDCA over the last 20 years has not changed the incidence of severe CFLD, leading to questions about the use of this treatment in young children given its possible adverse effects.
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Affiliation(s)
- Pierre‐Yves Boëlle
- Sorbonne Université, INSERM, Institut Pierre Louis d’épidémiologie et de Santé Publique, IPLESP, APHP, Hôpital Saint‐AntoineParisFrance
| | - Dominique Debray
- Pediatric Hepatology UnitAP‐HP, Hôpital Necker Enfants MaladesParisFrance,Sorbonne Université, INSERM, Centre de Recherche Saint‐Antoine, CRSAParisFrance
| | - Loic Guillot
- Sorbonne Université, INSERM, Centre de Recherche Saint‐Antoine, CRSAParisFrance
| | - Annick Clement
- Pediatric Pulmonology DepartmentAP‐HP, Hôpital TrousseauParisFrance,Physiopathologie des Maladies Genetiques d’Expression PediatriqueSorbonne Université, INSERMParisFrance
| | - Harriet Corvol
- Sorbonne Université, INSERM, Centre de Recherche Saint‐Antoine, CRSAParisFrance,Pediatric Pulmonology DepartmentAP‐HP, Hôpital TrousseauParisFrance
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32
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Freeman AJ, Sellers ZM, Mazariegos G, Kelly A, Saiman L, Mallory G, Ling SC, Narkewicz MR, Leung DH. A Multidisciplinary Approach to Pretransplant and Posttransplant Management of Cystic Fibrosis-Associated Liver Disease. Liver Transpl 2019; 25:640-657. [PMID: 30697907 DOI: 10.1002/lt.25421] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 01/09/2019] [Indexed: 12/16/2022]
Abstract
Approximately 5%-10% of patients with cystic fibrosis (CF) will develop advanced liver disease with portal hypertension, representing the third leading cause of death among patients with CF. Cystic fibrosis with advanced liver disease and portal hypertension (CFLD) represents the most significant risk to patient mortality, second only to pulmonary or lung transplant complications in patients with CF. Currently, there is no medical therapy to treat or reverse CFLD. Liver transplantation (LT) in patients with CFLD with portal hypertension confers a significant survival advantage over those who do not receive LT, although the timing in which to optimize this benefit is unclear. Despite the value and efficacy of LT in selected patients with CFLD, established clinical criteria outlining indications and timing for LT as well as disease-specific transplant considerations are notably absent. The goal of this comprehensive and multidisciplinary report is to present recommendations on the unique CF-specific pre- and post-LT management issues clinicians should consider and will face.
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Affiliation(s)
- A Jay Freeman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Atlanta, GA
| | - Zachary M Sellers
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, Lucile Packard Children's Hospital at Stanford, Palo Alto, CA
| | - George Mazariegos
- Department of Surgery and Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Andrea Kelly
- Department of Pediatrics, Perelman School of Medicine of University of Pennsylvania, Philadelphia, PA.,Division of Pediatric Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Medical Center, New York, NY.,Division of Pediatric Infectious Diseases, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - George Mallory
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.,Divisions of Pediatric Pulmonary Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Simon C Ling
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, Toronto, Ontario, Canada
| | - Michael R Narkewicz
- Digestive Health Institute, Children's Hospital of Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Daniel H Leung
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.,Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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33
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Alexopoulou A, Pouriki S, Vasilieva L, Alexopoulos T, Filaditaki V, Gioka M, Diamantea F, Dourakis SP. Evaluation of noninvasive markers for the diagnosis of cystic fibrosis liver disease. Scand J Gastroenterol 2018; 53:1547-1552. [PMID: 30600723 DOI: 10.1080/00365521.2018.1534986] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES In cystic fibrosis (CF), liver disease (LD) is the third leading cause of mortality. As liver biopsy was considered inconsistent in CFLD diagnosis, a combination of modalities were utilized in the conventional Debray criteria (DC). More recently, noninvasive liver fibrosis biomarkers were applied by Koh et al (New criteria-NC). In the current study, we aimed to evaluate noninvasive biomarkers for the CFLD diagnosis. METHODS Longitudinal data were collected from a cohort of genetically confirmed CF patients. CFLD was diagnosed by both DC and NC. Apart from transient elastography (TE) > 6.8 kPa, biomarkers incorporated in the NC included AST/ALT-ratio (AAR) ≥ 1, FIB-4 index ≥3.25 and APRI >0.50. RESULTS 62 patients with CF, [56.5% male, age at enrollment 25 (22-31) years], were prospectively followed-up for 33 (28-36) months. Sixteen (25.8%) and 27 (43.5%) patients met DC and NC, respectively. Twenty-four fulfilling NC had at least one positive biomarker (6 TE, 7 AAR, 6 both TE and AAR, 2 both APRI and AAR and 3 both APRI and TE). Thirteen (48.1%) had diffuse LD/cirrhosis by the NC and all had at least one additional parameter classifying them as CFLD. From the 14 (51.8%) with no-diffuse-LD, 64.3%, 14.3% and 21.4% had 2, 3 and 4 of the necessary modalities incorporated in NC, respectively, confirming their classification as CFLD. TE was 100% specific to rule in CFLD but had a moderate sensitivity. CONCLUSIONS NC were able to identify 17.7% more CFLD patients compared to DC. The multiple biomarkers incorporated in NC may enhance the ability to detect CFLD.
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Affiliation(s)
- Alexandra Alexopoulou
- a 2nd Department of Internal Medicine and Research Laboratory , Medical School, National and Kapodistrian University of Athens, Hippokration Hospital , Athens , Greece
| | - Sophia Pouriki
- a 2nd Department of Internal Medicine and Research Laboratory , Medical School, National and Kapodistrian University of Athens, Hippokration Hospital , Athens , Greece
| | - Larisa Vasilieva
- a 2nd Department of Internal Medicine and Research Laboratory , Medical School, National and Kapodistrian University of Athens, Hippokration Hospital , Athens , Greece
| | - Theodoros Alexopoulos
- a 2nd Department of Internal Medicine and Research Laboratory , Medical School, National and Kapodistrian University of Athens, Hippokration Hospital , Athens , Greece
| | - Vasiliki Filaditaki
- b Third Respiratory Medicine Department , Sismanogleio General Hospital , Athens , Greece
| | - Maria Gioka
- b Third Respiratory Medicine Department , Sismanogleio General Hospital , Athens , Greece
| | - Filia Diamantea
- b Third Respiratory Medicine Department , Sismanogleio General Hospital , Athens , Greece
| | - Spyros P Dourakis
- a 2nd Department of Internal Medicine and Research Laboratory , Medical School, National and Kapodistrian University of Athens, Hippokration Hospital , Athens , Greece
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Calvopina DA, Chatfield MD, Weis A, Coleman MA, Fernandez-Rojo MA, Noble C, Ramm LE, Leung DH, Lewindon PJ, Ramm GA. MicroRNA Sequencing Identifies a Serum MicroRNA Panel, Which Combined With Aspartate Aminotransferase to Platelet Ratio Index Can Detect and Monitor Liver Disease in Pediatric Cystic Fibrosis. Hepatology 2018; 68:2301-2316. [PMID: 30014495 DOI: 10.1002/hep.30156] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/27/2018] [Indexed: 02/06/2023]
Abstract
Cystic fibrosis (CF)-associated liver disease (CFLD) is a hepatobiliary complication of CF. Current diagnostic modalities rely on nonspecific assessments, whereas liver biopsy is the gold standard to assess severity of fibrosis. MicroRNAs (miRNAs) regulate liver disease pathogenesis and are proposed as diagnostic biomarkers. We investigated the combined use of serum miRNAs and aspartate aminotransferase (AST) to platelet ratio (APRI) to diagnose and assess CFLD severity. This was a cross-sectional cohort study of the circulatory miRNA signature of 124 children grouped by clinical, biochemical, and imaging assessments as follows: CFLD (n = 44), CF patients with no evidence of liver disease (CFnoLD; n = 40), and healthy controls (n = 40). Serum miRNAs were analyzed using miRNA sequencing (miRNA-Seq). Selected differentially expressed serum miRNA candidates were further validated by qRT-PCR and statistical analysis performed to evaluate utility to predict CFLD and fibrosis severity validated by liver biopsy, alone or in combination with APRI. Serum miR-122-5p, miR-365a-3p, and miR-34a-5p levels were elevated in CFLD compared to CFnoLD, whereas miR-142-3p and let-7g-5p were down-regulated in CFLD compared to CFnoLD. Logistic regression analysis combining miR-365a-3p, miR-142-3p, and let-7g-5p with APRI showed 21 times greater odds of accurately predicting liver disease in CF with an area under the receiver operating characteristics curve (AUROC) = 0.91 (sensitivity = 83%, specificity = 92%; P < 0.0001). Expression levels of serum miR-18a-5p were correlated with increasing hepatic fibrosis (HF) stage in CFLD (rs = 0.56; P < 0.0001), showing good diagnostic accuracy for distinguishing severe (F3-F4) from mild/moderate fibrosis (F0-F2). A unit increase of miR-18a-5p showed a 7-fold increased odds of having severe fibrosis with an AUROC = 0.82 (sensitivity = 93%, specificity = 73%; P = 0.004), indicating its potential to predict fibrosis severity. Conclusion: We identified a distinct circulatory miRNA profile in pediatric CFLD with potential to accurately discriminate liver disease and fibrosis severity in children with CF.
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Affiliation(s)
- Diego A Calvopina
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Mark D Chatfield
- QIMR Berghofer Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Anna Weis
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Miranda A Coleman
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | | | - Charlton Noble
- Department of Gastroenterology and Hepatology, Lady Cilento Children's Hospital, South Brisbane, QLD, Australia
| | - Louise E Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Daniel H Leung
- Department of Pediatrics, Baylor College of Medicine, Houston, TX.,Division of Pediatric Gastroenterology, Hepatology, Nutrition, Texas Children's Liver Center, Houston, TX
| | - Peter J Lewindon
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Gastroenterology and Hepatology, Lady Cilento Children's Hospital, South Brisbane, QLD, Australia
| | - Grant A Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Abstract
The inherited diseases causing conjugated hyperbilirubinemia are diverse, with variability in clinical severity, histologic appearance, and time of onset. The liver biopsy appearances can also vary depending on whether the initial presentation is in the neonatal period or later. Although many of the disorders have specific histologic features in fully developed and classic cases, biopsies taken early in the disease course may be nonspecific, showing either cholestatic hepatitis or an obstructive pattern of injury requiring close correlation with the laboratory and clinical findings to reach the correct diagnosis. Additionally, increased understanding of the range of hepatic changes occurring in mild deficiencies of bile canalicular transporter proteins suggest that these disorders, particularly ABCB4 deficiency, may be more common than previously recognized; improved awareness should prompt further investigation.
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Affiliation(s)
- Andrew D Clouston
- Faculty of Medicine, University of Queensland, Herston Road, Brisbane, Queensland 4006, Australia.
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36
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Bolia R, Ooi CY, Lewindon P, Bishop J, Ranganathan S, Harrison J, Ford K, van der Haak N, Oliver MR. Practical approach to the gastrointestinal manifestations of cystic fibrosis. J Paediatr Child Health 2018; 54:609-619. [PMID: 29768684 DOI: 10.1111/jpc.13921] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/07/2018] [Accepted: 03/02/2018] [Indexed: 12/14/2022]
Abstract
Cystic fibrosis (CF) is the most common, life-shortening, genetic illness affecting children in Australia and New Zealand. The genetic abnormality results in abnormal anion transport across the apical membrane of epithelial cells in a number of organs, including the lungs, gastrointestinal tract, liver and genito-urinary tract. Thus, CF is a multi-system disorder that requires a multi-disciplinary approach. Respiratory disease is the predominant cause of both morbidity and mortality in patients with CF. However, there are significant and clinically relevant gastrointestinal, liver, pancreatic and nutritional manifestations that must be detected and managed in a timely and structured manner. The aim of this review is to provide evidence-based information and clinical algorithms to guide the nutritional and gastrointestinal management of patients with CF.
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Affiliation(s)
- Rishi Bolia
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Chee Y Ooi
- School of Women and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,miCF Research Centre and Department of Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Peter Lewindon
- Department of Gastroenterology, Lady Cilento Children's Hospital and Queensland Liver Transplant Service, Brisbane, Queensland, Australia
| | - Jonathan Bishop
- Department of Paediatric Gastroenterology, Starship Children's Hospital, Auckland, New Zealand
| | - Sarath Ranganathan
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Jo Harrison
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Kristyn Ford
- Department of Nutrition and Dietetics, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Natalie van der Haak
- Department of Nutrition and Dietetics, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Mark R Oliver
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
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Abstract
PURPOSE OF REVIEW The aim of this study was to provide an overview of the current understanding of the pathophysiology, diagnosis and management of cystic fibrosis-liver disease (CFLD). RECENT FINDINGS CFLD has a variety of manifestations. Previously, it was thought that patients progressed from mild cholestatic disease to cirrhosis to decompensated cirrhosis with portal hypertension. Newer evidence suggests that some patients may develop cirrhosis while others develop noncirrhotic portal hypertension. Advances in our understanding of the pathophysiology of disease necessitate modifications to the current diagnostic criteria. Both fibroscan and noninvasive biomarkers can be used to identify patients with cirrhosis and portal hypertension. Ursodeoxycholic acid remains the mainstay of therapy despite a paucity of rigorous studies supporting its use. Novel therapeutic agents such as CF transmembrane conductance regulator (CFTR) modulators and potentiators are encouraging but need to be evaluated specifically in CFLD. SUMMARY A better understanding of the pathophysiology of disease is critical to developing more disease-specific diagnostics and therapeutics.
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38
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Abstract
PURPOSE OF REVIEW To provide an insight and overview of the challenges in the diagnosis, follow-up and treatment of cystic fibrosis-related liver disease (CFLD). RECENT FINDINGS The variable pathophysiology of CFLD complicates its diagnosis and treatment. A 'gold standard' for CFLD diagnosis is lacking. Over the past years, new techniques to diagnose features of CFLD, such as transient elastography, have been investigated. Although most of these tests confirm cystic fibrosis-related liver involvement (CFLI), they are, however, not suitable to distinguish various phenotypical presentations or predict progression to clinically relevant cirrhosis or portal hypertension. A combined initiative from the European and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition has been started, aimed to obtain consensus on CFLD criteria and definitions. Currently, only ursodeoxycholic acid is used in CFLD treatment, although it has not been convincingly demonstrated to change the natural course of the disease. Drugs that directly target cystic fibrosis transmembrane conductance regulator protein dysfunction show promising results; however, more long-term follow-up and validation studies are needed. SUMMARY CFLD is an umbrella term referring to a wide variety of liver manifestations with variable clinical needs and consequences. CFLD with portal hypertension is the most severe form of CFLD due to its significant implications on morbidity and mortality. The clinical relevance of other CFLI is uncertain. Consensus on CFLD definitions is essential to validate new diagnostic tools and therapeutic outcome measures.
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Hillaire S, Cazals-Hatem D, Erlinger S, Paradis V. Cystic fibrosis liver disease in adults: Limits of noninvasive tests of fibrosis. Hepatology 2018; 67:798-799. [PMID: 29105109 DOI: 10.1002/hep.29637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 09/26/2017] [Accepted: 10/06/2017] [Indexed: 12/07/2022]
Affiliation(s)
- Sophie Hillaire
- Department of Medicine and CRCM, Hôpital Foch, Suresnes, France
| | | | | | - Valerie Paradis
- Université Paris 7, Paris and Department of Pathology Hôpital Beaujon AP-HP, Clichy, France
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40
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Leung DH, Narkewicz MR. Cystic Fibrosis-related cirrhosis. J Cyst Fibros 2017; 16 Suppl 2:S50-S61. [DOI: 10.1016/j.jcf.2017.07.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/01/2017] [Accepted: 07/03/2017] [Indexed: 12/14/2022]
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41
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Hillaire S, Cazals-Hatem D, Bruno O, de Miranda S, Grenet D, Poté N, Soubrane O, Erlinger S, Lacaille F, Mellot F, Vilgrain V, Paradis V. Liver transplantation in adult cystic fibrosis: Clinical, imaging, and pathological evidence of obliterative portal venopathy. Liver Transpl 2017; 23:1342-1347. [PMID: 28816015 DOI: 10.1002/lt.24842] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/12/2017] [Accepted: 07/14/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Sophie Hillaire
- Department of Medicine, Centre de Resources et de Compétence de la Mucoviscidose, Hôpital Foch, Suresnes, France
| | | | - Onorina Bruno
- Department of Radiology, Hôpital Beaujon AP-HP, Clichy, France
| | - Sandra de Miranda
- Department of Pulmonology, Centre de Resources et de Compétence de la Mucoviscidose, Hôpital Foch, Suresnes, France
| | - Dominique Grenet
- Department of Pulmonology, Centre de Resources et de Compétence de la Mucoviscidose, Hôpital Foch, Suresnes, France
| | - Nicolas Poté
- Department of Pulmonology, Centre de Resources et de Compétence de la Mucoviscidose, Hôpital Foch, Suresnes, France.,Department of Pathology, Hôpital Beaujon AP-HP, Clichy, France.,Department of Radiology, Hôpital Beaujon AP-HP, Clichy, France.,Department of Liver Transplantation Surgery, Hôpital Beaujon AP-HP, Clichy, France.,Université Paris 7, Paris, France
| | - Olivier Soubrane
- Department of Liver Transplantation Surgery, Hôpital Beaujon AP-HP, Clichy, France.,Université Paris 7, Paris, France
| | | | - Florence Lacaille
- Hôpital Necker, Service d'Hépato-Gastroentérologie Pédiatrique AP-HP, Paris, France
| | - Francois Mellot
- Department of Radiology, Centre de Resources et de Compétence de la Mucoviscidose, Hôpital Foch, Suresnes, France
| | - Valerie Vilgrain
- Department of Pulmonology, Centre de Resources et de Compétence de la Mucoviscidose, Hôpital Foch, Suresnes, France.,Department of Radiology, Hôpital Beaujon AP-HP, Clichy, France.,Department of Liver Transplantation Surgery, Hôpital Beaujon AP-HP, Clichy, France.,Université Paris 7, Paris, France
| | - Valerie Paradis
- Department of Pulmonology, Centre de Resources et de Compétence de la Mucoviscidose, Hôpital Foch, Suresnes, France.,Department of Pathology, Hôpital Beaujon AP-HP, Clichy, France.,Department of Radiology, Hôpital Beaujon AP-HP, Clichy, France.,Department of Liver Transplantation Surgery, Hôpital Beaujon AP-HP, Clichy, France.,Université Paris 7, Paris, France
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42
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Taurocholate Induces Biliary Differentiation of Liver Progenitor Cells Causing Hepatic Stellate Cell Chemotaxis in the Ductular Reaction: Role in Pediatric Cystic Fibrosis Liver Disease. THE AMERICAN JOURNAL OF PATHOLOGY 2017; 187:2744-2757. [PMID: 28935574 DOI: 10.1016/j.ajpath.2017.08.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 07/14/2017] [Accepted: 08/11/2017] [Indexed: 02/07/2023]
Abstract
Cystic fibrosis liver disease (CFLD) in children causes progressive fibrosis leading to biliary cirrhosis; however, its cause(s) and early pathogenesis are unclear. We hypothesized that a bile acid-induced ductular reaction (DR) drives fibrogenesis. The DR was evaluated by cytokeratin-7 immunohistochemistry in liver biopsies, staged for fibrosis, from 60 children with CFLD, and it demonstrated that the DR was significantly correlated with hepatic fibrosis stage and biliary taurocholate levels. To examine the mechanisms involved in DR induction, liver progenitor cells (LPCs) were treated with taurocholate, and key events in DR evolution were assessed: LPC proliferation, LPC biliary differentiation, and hepatic stellate cell (HSC) chemotaxis. Taurocholate induced a time-dependent increase in LPC proliferation and expression of genes associated with cholangiocyte differentiation (cytokeratin 19, connexin 43, integrin β4, and γ-glutamyltranspeptidase), whereas the hepatocyte specification marker HNF4α was suppressed. Functional cholangiocyte differentiation was demonstrated via increased acetylated α-tubulin and SOX9 proteins, the number of primary cilia+ LPCs, and increased active γ-glutamyltranspeptidase enzyme secretion. Taurocholate induced LPCs to release MCP-1, MIP1α, and RANTES into conditioned medium causing HSC chemotaxis, which was inhibited by anti-MIP1α. Immunofluorescence confirmed chemokine expression localized to CK7+ DR and LPCs in CFLD liver biopsies. This study suggests that taurocholate is involved in initiating functional LPC biliary differentiation and the development of the DR, with subsequent induction of chemokines that drive HSC recruitment in CFLD.
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43
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Baldassarre A, Felli C, Prantera G, Masotti A. Circulating microRNAs and Bioinformatics Tools to Discover Novel Diagnostic Biomarkers of Pediatric Diseases. Genes (Basel) 2017; 8:genes8090234. [PMID: 28925938 PMCID: PMC5615367 DOI: 10.3390/genes8090234] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 09/08/2017] [Accepted: 09/12/2017] [Indexed: 12/17/2022] Open
Abstract
MicroRNAs (miRNAs) are small noncoding RNAs that regulate gene expression at the post-transcriptional level. Current studies have shown that miRNAs are also present in extracellular spaces, packaged into various membrane-bound vesicles, or associated with RNA-binding proteins. Circulating miRNAs are highly stable and can act as intercellular messengers to affect many physiological processes. MicroRNAs circulating in body fluids have generated strong interest in their potential use as clinical biomarkers. In fact, their remarkable stability and the relative ease of detection make circulating miRNAs ideal tools for rapid and non-invasive diagnosis. This review summarizes recent insights about the origin, functions and diagnostic potential of extracellular miRNAs by especially focusing on pediatric diseases in order to explore the feasibility of alternative sampling sources for the development of non-invasive pediatric diagnostics. We will also discuss specific bioinformatics tools and databases for circulating miRNAs focused on the identification and discovery of novel diagnostic biomarkers of pediatric diseases.
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Affiliation(s)
| | - Cristina Felli
- Bambino Gesù Children's Hospital-IRCCS, Research Laboratories, 00146 Rome, Italy.
| | - Giorgio Prantera
- Department of Ecology and Biology, Università della Tuscia, 01100 Viterbo, Italy.
| | - Andrea Masotti
- Bambino Gesù Children's Hospital-IRCCS, Research Laboratories, 00146 Rome, Italy.
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Koh C, Sakiani S, Surana P, Zhao X, Eccleston J, Kleiner DE, Herion D, Liang TJ, Hoofnagle JH, Chernick M, Heller T. Adult-onset cystic fibrosis liver disease: Diagnosis and characterization of an underappreciated entity. Hepatology 2017; 66:591-601. [PMID: 28422310 PMCID: PMC5519421 DOI: 10.1002/hep.29217] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/22/2017] [Accepted: 04/14/2017] [Indexed: 12/15/2022]
Abstract
UNLABELLED Cystic fibrosis (CF) liver disease (CFLD), a leading cause of death in CF, is mostly described in pediatric populations. Adult-onset CFLD lacks sufficient characterization and diagnostic tools. A cohort of CF patients without CFLD during childhood were followed for up to 38 years with serologic testing, imaging, and noninvasive fibrosis markers. Historical CFLD diagnostic criteria were compared with newly proposed CFLD criteria. Thirty-six CF patients were followed for a median of 24.5 years (interquartile range 15.6-32.9). By the last follow-up, 11 (31%) had died. With conventional criteria, 8 (22%) patients had CFLD; and by the new criteria, 17 (47%) had CFLD at a median age of 36.6 years (interquartile range 26.5-43.2). By the new criteria, those with CFLD had higher median alanine aminotransferase (42 versus 27, P = 0.005), aspartate aminotransferase (AST; 26 versus 21, P = 0.01), direct bilirubin (0.13 versus 0.1, P = 0.01), prothrombin time (14.4 versus 12.4, P = 0.002), and AST-to-platelet ratio index (0.31 versus 0.23, P = 0.003) over the last 2 years of follow-up. Subjects with a FibroScan >6.8 kPa had higher alanine aminotransferase (42 versus 28U/L, P = 0.02), AST (35 versus 25U/L, P = 0.02), AST-to-platelet ratio index (0.77 versus 0.25, P = 0.0004), and Fibrosis-4 index (2.14 versus 0.74, P = 0.0003) and lower platelet counts (205 versus 293, P = 0.02). One CFLD patient had nodular regenerative hyperplasia. Longitudinally, mean platelet counts significantly declined in the CFLD group (from 310 to 230 U/L, P = 0.0005). Deceased CFLD patients had lower platelet counts than those alive with CFLD (143 versus 258 U/L, P = 0.004) or those deceased with no CFLD (143 versus 327U/L, P = 0.006). CONCLUSION Adult-onset CFLD may be more prevalent than previously described, which suggests a later wave of CFLD that impacts morbidity; routine liver tests, radiologic imaging, noninvasive fibrosis markers, and FibroScan can be used algorithmically to identify adult CFLD; and further evaluation in other CF cohorts should be performed for validation. (Hepatology 2017;66:591-601).
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Affiliation(s)
- Christopher Koh
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Sasan Sakiani
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Pallavi Surana
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Xiongce Zhao
- Office of the Director, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jason Eccleston
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David E. Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - David Herion
- Department of Clinical Research Informatics, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - T. Jake Liang
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jay H. Hoofnagle
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Milica Chernick
- Office of the Director, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
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45
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Correlation of Transient Elastography With Severity of Cystic Fibrosis-related Liver Disease. J Pediatr Gastroenterol Nutr 2017; 64:505-511. [PMID: 27782957 DOI: 10.1097/mpg.0000000000001448] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The aim of the study was to evaluate whether liver stiffness measurement (LSM), determined by transient elastography, correlates with presence and severity of liver disease in children and young adults with cystic fibrosis (CF). METHODS Subjects underwent LSM at routine CF visits. Presence and severity of cystic fibrosis liver disease (CFLD) was determined by clinical parameters. Subjects were classified as no CFLD, CFLD without portal hypertension (PHTN), and CFLD with PHTN. LSM was compared with aspartate aminotransferase/platelet ratio index (APRI) as a correlate to severity of CFLD. RESULTS A total of 249 subjects (53% boys; mean age 14 ± 7 years; 7 [3%] <2 years and 74 [30%] 18-25 years) underwent LSM. Subjects were classified as 158 (64%) with no CFLD, 73 (29%) CFLD without PHTN, and 18 (7%) CFLD with PHTN. The median (interquartile range) LSM was different among the 3 groups: 4.4 (3.8-5.4), 5.1 (4.4-6.3), and 14.1 (8.8-24.8) kPa, respectively, with all pairwise comparisons different from one another (P < 0.0001). Similarly, median (interquartile range) APRI was different in groups 1 and 2 compared with CFLD with PHTN: 0.22 (0.17-0.27), 0.24 (0.17-0.33), and 0.53 (0.24-0.84), respectively (P < 0.01). Analysis of receiver operating characteristics for discriminating CFLD with PHTN from the other groups resulted in cut-points at 6.2 kPa (LSM) and 0.35 (APRI). LSM was superior to APRI in discriminating CFLD with PHTN from other groups, with areas under the curve 0.91 (LSM) versus 0.78 (APRI) (P = 0.05). CONCLUSIONS Liver stiffness, as determined by transient elastography, correlates with the presence and severity of CFLD. Although APRI provided some information regarding severity of liver disease, LSM performed better than APRI in this population.
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46
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Imaging the Abdominal Manifestations of Cystic Fibrosis. Int J Hepatol 2017; 2017:5128760. [PMID: 28250993 PMCID: PMC5303593 DOI: 10.1155/2017/5128760] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 12/17/2016] [Accepted: 01/09/2017] [Indexed: 02/07/2023] Open
Abstract
Cystic fibrosis (CF) is a multisystem disease with a range of abdominal manifestations including those involving the liver, pancreas, and kidneys. Recent advances in management of the respiratory complications of the disease has led to a greater life expectancy in patients with CF. Subsequently, there is increasing focus on the impact of abdominal disease on quality of life and survival. Liver cirrhosis is the most important extrapulmonary cause of death in CF, yet significant challenges remain in the diagnosis of CF related liver disease. The capacity to predict those patients at risk of developing cirrhosis remains a significant challenge. We review representative abdominal imaging findings in patients with CF selected from the records of two academic health centres, with a view to increasing familiarity with the abdominal manifestations of the disease. We review their presentation and expected imaging findings, with a focus on the challenges facing diagnosis of the hepatic manifestations of the disease. An increased familiarity with these abdominal manifestations will facilitate timely diagnosis and management, which is paramount to further improving outcomes for patients with cystic fibrosis.
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47
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Sathe MN, Freeman AJ. Gastrointestinal, Pancreatic, and Hepatobiliary Manifestations of Cystic Fibrosis. Pediatr Clin North Am 2016; 63:679-98. [PMID: 27469182 DOI: 10.1016/j.pcl.2016.04.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pulmonary disease is the primary cause of morbidity and mortality in people with cystic fibrosis (CF), but significant involvement within gastrointestinal, pancreatic, and hepatobiliary systems occurs as well. As in the airways, defects in CFTR alter epithelial surface fluid, mucus viscosity, and pH, increasing risk of stasis through the various hollow epithelial-lined structures of the gastrointestinal tract. This exerts secondary influences that are responsible for most gastrointestinal, pancreatic, and hepatobiliary manifestations of CF. Understanding these gastrointestinal morbidities of CF is essential in understanding and treating CF as a multisystem disease process and improving overall patient care.
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Affiliation(s)
- Meghana Nitin Sathe
- Division of Pediatric Gastroenterology and Nutrition, Children's Health, University of Texas Southwestern, F4.06, 1935 Medical District Drive, Dallas, TX 75235, USA
| | - Alvin Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University, 2015 Uppergate Drive, Northeast, Atlanta, GA 30322, USA.
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48
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Riggio O, Gioia S, Pentassuglio I, Nicoletti V, Valente M, d’Amati G. Idiopathic noncirrhotic portal hypertension: current perspectives. Hepat Med 2016; 8:81-8. [PMID: 27555800 PMCID: PMC4968980 DOI: 10.2147/hmer.s85544] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The term idiopathic noncirrhotic portal hypertension (INCPH) has been recently proposed to replace terms, such as hepatoportal sclerosis, idiopathic portal hypertension, incomplete septal cirrhosis, and nodular regenerative hyperplasia, used to describe patients with a hepatic presinusoidal cause of portal hypertension of unknown etiology, characterized by features of portal hypertension (esophageal varices, nonmalignant ascites, porto-venous collaterals), splenomegaly, patent portal, and hepatic veins and no clinical and histological signs of cirrhosis. Physicians should learn to look for this condition in a number of clinical settings, including cryptogenic cirrhosis, a disease known to be associated with INCPH, drug administration, and even chronic alterations in liver function tests. Once INCPH is clinically suspected, liver histology becomes mandatory for the correct diagnosis. However, pathologists should be familiar with the histological features of INCPH, especially in cases in which histology is not only requested to exclude liver cirrhosis.
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Affiliation(s)
- Oliviero Riggio
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension
| | - Stefania Gioia
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension
| | - Ilaria Pentassuglio
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension
| | - Valeria Nicoletti
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension
| | - Michele Valente
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Giulia d’Amati
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
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Relevance of 3D Cholangiography and Transient Elastography to Assess Cystic Fibrosis-Associated Liver Disease? Can Respir J 2016; 2016:4592702. [PMID: 27445541 PMCID: PMC4939173 DOI: 10.1155/2016/4592702] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 05/25/2016] [Accepted: 06/02/2016] [Indexed: 12/14/2022] Open
Abstract
Background. Cystic fibrosis-associated liver disease (CFLD) is a major cause of death. The objective of our retrospective study was to describe the relevance of magnetic resonance imaging (MRI) and liver stiffness measurement (LSM) for CFLD evaluation. Methods. All cystic fibrosis adult patients evaluated by MRI and LSM were included. MR signs of portal hypertension (PHT), dysmorphia, or cholangitis were collected and LSM expressed in kPa and Metavir. Results. Of 25 patients, 52% had abnormal MRI. Median LSM was 5.7 kPa (3.4–9.9). Three patients had F2 score and one had F3 score. In patients with PHT, LSM was 7.85 kPa (3.7–9.9) compared to 5 (3.4–7.5) in others, p = 0.02. In patients with abnormal liver function tests, 50% had increased LSM (≥F2), whereas 94% with normal tests had normal LSM (p = 0.04). Seven patients had abnormal MRI despite normal ultrasonography. Conclusions. MRI and LSM provide useful information on CFLD and may help to screen patients with PHT.
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Abstract
Cystic fibrosis is a life-limiting, recessive disease caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Increased survival outcomes and the multisystem nature of the disease, including the involvement of hepatobiliary and gastrointestinal tracts, now require the need for more extensive knowledge and expertise in cystic fibrosis among gastroenterologists. Manifestations are either a direct consequence of the primary defect in cystic fibrosis or a secondary complication of the disease or therapy. Adult patients with cystic fibrosis also have an increased risk of malignancy in the gastrointestinal and pancreatico-biliary tracts compared with the general population. Novel treatments that target the basic defects in the CFTR protein have emerged, but to date not much is known about their effects on the gastrointestinal and hepatobiliary systems. The introduction of such therapies has provided new opportunities for the application of intestinal endpoints in clinical trials and the understanding of underlying disease mechanisms that affect the gut in cystic fibrosis.
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Affiliation(s)
- Chee Y Ooi
- Sydney Children's Hospital, School of Women's and Children's Health, High Street, Randwick, New South Wales 2031, Sydney, Australia
| | - Peter R Durie
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children 555 University Avenue Toronto, Ontario M5G 1X8, Canada
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