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Valamparampil J, Gupte GL. Spectrum of renal lesions in infantile cholestasis. Clin Liver Dis (Hoboken) 2024; 23:e0150. [PMID: 38623147 PMCID: PMC11018225 DOI: 10.1097/cld.0000000000000150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 02/05/2024] [Indexed: 04/17/2024] Open
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Sadiq J, Lloyd C, Hodson J, Trapero Marugan M, Ferguson J, Sharif K, Mirza DF, Hirschfield G, Kelly D. Long-term clinical and socioeconomic outcomes of children with biliary atresia. JGH Open 2023; 7:841-847. [PMID: 38162865 PMCID: PMC10757476 DOI: 10.1002/jgh3.12980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 08/28/2023] [Accepted: 10/02/2023] [Indexed: 01/03/2024]
Abstract
Background Biliary atresia (BA) is rare liver disease of unknown etiology, and is a major indication for liver transplant (LT). Previous data indicate improved outcomes with early referral for Kasai portoenterostomy (KPE). Objective Evaluate the long-term outcomes in BA, with particular focus on those transitioned to adult care with native livers. Subjects and Methods Patients with BA treated between1980 and 2012 were identified. Data were collected from the time of referral, transition to adult care, and the most recent clinic notes, from which patient and native liver survival were calculated. Results Four hundred and fifty-four patients with BA were identified, who were followed up for median of 16.4 years from birth; 74 died (41 of whom had a LT), giving a 20-year survival rate of 83.6%. Two hundred and seventy-two patients received an LT, with the median native liver survival being 35 months. Of patients who transitioned to adult care, 54 of 180 (30.0%) retained their native liver. Of these, 72% (39 of 54) had evidence of chronic liver disease at transition, of whom 8 were subsequently lost to follow-up, 9 were transplanted, and 22 remained stable with compensated liver disease. Of the 15 of 54 patients (28%) with no evidence of chronic disease in their native liver disease at transition, 3 were subsequently lost to follow-up; none received transplants, although 3 patients developed new-onset liver disease. All patients transitioned to adult care completed secondary school education (N = 180), with 49% having attended college/university and 87% being in employment or education at the last follow-up. Of female patients, 34% had at least one pregnancy (27 children in 21 women), while 22% of males had fathered a child. Conclusion Long-term outcomes in BA are good, with patients surviving into adult life. Progression of chronic liver disease and associated morbidity is common in those who retained their native livers, suggesting that these patients require monitoring of liver disease throughout adult life, and early recognition of the need for LT.
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Affiliation(s)
- Javaid Sadiq
- Birmingham Women's & Children's Hospital& University Hospital BirminghamBirminghamUK
| | - Carla Lloyd
- Birmingham Women's & Children's Hospital& University Hospital BirminghamBirminghamUK
| | - James Hodson
- Institute of Translational MedicineUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
- Research Development and InnovationUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Maria Trapero Marugan
- Centre for Liver ResearchNIHR Biomedical Research Unit, University of BirminghamBirminghamUK
| | - James Ferguson
- Centre for Liver ResearchNIHR Biomedical Research Unit, University of BirminghamBirminghamUK
| | - Khalid Sharif
- Birmingham Women's & Children's Hospital& University Hospital BirminghamBirminghamUK
| | - Darius F Mirza
- Birmingham Women's & Children's Hospital& University Hospital BirminghamBirminghamUK
- Centre for Liver ResearchNIHR Biomedical Research Unit, University of BirminghamBirminghamUK
| | - Gideon Hirschfield
- Centre for Liver ResearchNIHR Biomedical Research Unit, University of BirminghamBirminghamUK
| | - Deirdre Kelly
- Birmingham Women's & Children's Hospital& University Hospital BirminghamBirminghamUK
- Centre for Liver ResearchNIHR Biomedical Research Unit, University of BirminghamBirminghamUK
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Glessner JT, Ningappa MB, Ngo KA, Zahid M, So J, Higgs BW, Sleiman PMA, Narayanan T, Ranganathan S, March M, Prasadan K, Vaccaro C, Reyes-Mugica M, Velazquez J, Salgado CM, Ebrahimkhani MR, Schmitt L, Rajasundaram D, Paul M, Pellegrino R, Gittes GK, Li D, Wang X, Billings J, Squires R, Ashokkumar C, Sharif K, Kelly D, Dhawan A, Horslen S, Lo CW, Shin D, Subramaniam S, Hakonarson H, Sindhi R. Biliary atresia is associated with polygenic susceptibility in ciliogenesis and planar polarity effector genes. J Hepatol 2023; 79:1385-1395. [PMID: 37572794 PMCID: PMC10729795 DOI: 10.1016/j.jhep.2023.07.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 07/07/2023] [Accepted: 07/18/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND & AIMS Biliary atresia (BA) is poorly understood and leads to liver transplantation (LT), with the requirement for and associated risks of lifelong immunosuppression, in most children. We performed a genome-wide association study (GWAS) to determine the genetic basis of BA. METHODS We performed a GWAS in 811 European BA cases treated with LT in US, Canadian and UK centers, and 4,654 genetically matched controls. Whole-genome sequencing of 100 cases evaluated synthetic association with rare variants. Functional studies included whole liver transcriptome analysis of 64 BA cases and perturbations in experimental models. RESULTS A GWAS of common single nucleotide polymorphisms (SNPs), i.e. allele frequencies >1%, identified intronic SNPs rs6446628 in AFAP1 with genome-wide significance (p = 3.93E-8) and rs34599046 in TUSC3 at sub-threshold genome-wide significance (p = 1.34E-7), both supported by credible peaks of neighboring SNPs. Like other previously reported BA-associated genes, AFAP1 and TUSC3 are ciliogenesis and planar polarity effectors (CPLANE). In gene-set-based GWAS, BA was associated with 6,005 SNPs in 102 CPLANE genes (p = 5.84E-15). Compared with non-CPLANE genes, more CPLANE genes harbored rare variants (allele frequency <1%) that were assigned Human Phenotype Ontology terms related to hepatobiliary anomalies by predictive algorithms, 87% vs. 40%, p <0.0001. Rare variants were present in multiple genes distinct from those with BA-associated common variants in most BA cases. AFAP1 and TUSC3 knockdown blocked ciliogenesis in mouse tracheal cells. Inhibition of ciliogenesis caused biliary dysgenesis in zebrafish. AFAP1 and TUSC3 were expressed in fetal liver organoids, as well as fetal and BA livers, but not in normal or disease-control livers. Integrative analysis of BA-associated variants and liver transcripts revealed abnormal vasculogenesis and epithelial tube formation, explaining portal vein anomalies that co-exist with BA. CONCLUSIONS BA is associated with polygenic susceptibility in CPLANE genes. Rare variants contribute to polygenic risk in vulnerable pathways via unique genes. IMPACT AND IMPLICATIONS Liver transplantation is needed to cure most children born with biliary atresia, a poorly understood rare disease. Transplant immunosuppression increases the likelihood of life-threatening infections and cancers. To improve care by preventing this disease and its progression to transplantation, we examined its genetic basis. We find that this disease is associated with both common and rare mutations in highly specialized genes which maintain normal communication and movement of cells, and their organization into bile ducts and blood vessels during early development of the human embryo. Because defects in these genes also cause other birth defects, our findings could lead to preventive strategies to lower the incidence of biliary atresia and potentially other birth defects.
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Affiliation(s)
- Joseph T Glessner
- Center for Applied Genomics (CAG), Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mylarappa B Ningappa
- Hillman Center for Pediatric Transplantation, UPMC-Children's Hospital of Pittsburgh, and Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kim A Ngo
- Department of Bioengineering, University of California, San Diego, San Diego, La Jolla, CA, USA
| | - Maliha Zahid
- Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Juhoon So
- Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brandon W Higgs
- Hillman Center for Pediatric Transplantation, UPMC-Children's Hospital of Pittsburgh, and Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick M A Sleiman
- Center for Applied Genomics (CAG), Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tejaswini Narayanan
- Department of Bioengineering, University of California, San Diego, San Diego, La Jolla, CA, USA
| | - Sarangarajan Ranganathan
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michael March
- Center for Applied Genomics (CAG), Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Krishna Prasadan
- Rangos Research Center Animal Imaging Core, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Courtney Vaccaro
- Center for Applied Genomics (CAG), Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Miguel Reyes-Mugica
- Division of Pediatric Pathology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Jeremy Velazquez
- Department of Pathology, School of Medicine, Pittsburgh Liver Research Center, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Claudia M Salgado
- Division of Pediatric Pathology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Mo R Ebrahimkhani
- Department of Pathology, School of Medicine, Pittsburgh Liver Research Center, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lori Schmitt
- Histology Core Laboratory Manager, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Dhivyaa Rajasundaram
- Department of Pediatrics, Division of Health Informatics, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Morgan Paul
- Hillman Center for Pediatric Transplantation, UPMC-Children's Hospital of Pittsburgh, and Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Renata Pellegrino
- Center for Applied Genomics (CAG), Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George K Gittes
- Surgeon-in-Chief Emeritus, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Dong Li
- Center for Applied Genomics (CAG), Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Xiang Wang
- Center for Applied Genomics (CAG), Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan Billings
- Center for Applied Genomics (CAG), Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Squires
- Pediatric Gastroenterology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Chethan Ashokkumar
- Hillman Center for Pediatric Transplantation, UPMC-Children's Hospital of Pittsburgh, and Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Khalid Sharif
- Paediatric Liver Unit Including Intestinal Transplantation, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Deirdre Kelly
- Paediatric Liver Unit Including Intestinal Transplantation, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Anil Dhawan
- Paediatric Liver GI and Nutrition Center and MowatLabs, NHS Foundation Trust, King's College Hospital, London, UK
| | - Simon Horslen
- Pediatric Gastroenterology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Cecilia W Lo
- Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donghun Shin
- Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shankar Subramaniam
- Department of Bioengineering, University of California, San Diego, San Diego, La Jolla, CA, USA; Department of Computer Science and Engineering, and Nanoengineering, University of California, San Diego, San Diego, La Jolla, CA, USA.
| | - Hakon Hakonarson
- Divisions of Human Genetics and Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Rakesh Sindhi
- Hillman Center for Pediatric Transplantation, UPMC-Children's Hospital of Pittsburgh, and Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA, USA.
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Grama A, Mititelu A, Sîrbe C, Benţa G, Pop TL. Immune-mediated cholangiopathies in children: the need to better understand the pathophysiology for finding the future possible treatment targets. Front Immunol 2023; 14:1206025. [PMID: 37928553 PMCID: PMC10623351 DOI: 10.3389/fimmu.2023.1206025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 09/28/2023] [Indexed: 11/07/2023] Open
Abstract
Cholangiopathies are defined as focal or extensive damage of the bile ducts. According to the pathogenetic mechanism, it may be immune-mediated or due to genetic, infectious, toxic, vascular, and obstructive causes. Their chronic evolution is characterized by inflammation, obstruction of bile flow, cholangiocyte proliferation, and progression toward fibrosis and cirrhosis. Immune-mediated cholangiopathies comprise primary sclerosing cholangitis (PSC), autoimmune cholangitis and IgG4-associated cholangitis in adults and biliary atresia (BA), neonatal sclerosing cholangitis (NSC) in children. The main purpose of this narrative review was to highlight the similarities and differences among immune-mediated cholangiopathies, especially those frequent in children in which cholangiocyte senescence plays a key role (BA, NSC, and PSC). These three entities have many similarities in terms of clinical and histopathological manifestations, and the distinction between them can be hard to achieve. In BA, bile duct destruction occurs due to aggression of the biliary cells due to viral infections or toxins during the intrauterine period or immediately after birth. The consequence is the activation of the immune system leading to severe inflammation and fibrosis of the extrahepatic biliary tract, lumen stenosis, and impairment of the biliary flow. PSC is characterized by inflammation and fibrosis of intra- and extrahepatic bile ducts, leading to secondary biliary cirrhosis. It is a multifactorial disease that occurs because of genetic predisposition [human leukocyte antigen (HLA) and non-HLA haplotypes], autoimmunity (cellular immune response, autoantibodies, association with inflammatory bowel disease), environmental factors (infections or toxic bile), and host factors (intestinal microbiota). NSC seems to be a distinct subgroup of childhood PSC that appears due to the interaction between genetic predisposition (HLA B8 and DR3) and the disruption of the immune system, validated by elevated IgG levels or specific antibodies [antinuclear antibody (ANA), anti-smooth muscle antibody (ASMA)]. Currently, the exact mechanism of immune cholangiopathy is not fully understood, and further data are required to identify individuals at high risk of developing these conditions. A better understanding of the immune mechanisms and pathophysiology of BA, NSC, and PSC will open new perspectives for future treatments and better methods of preventing severe evolution.
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Affiliation(s)
- Alina Grama
- 2Pediatric Discipline, Department of Mother and Child, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- 2Pediatric Clinic and Center of Expertise in Pediatric Liver Rare Disorders, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Alexandra Mititelu
- 2Pediatric Discipline, Department of Mother and Child, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- 2Pediatric Clinic and Center of Expertise in Pediatric Liver Rare Disorders, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Claudia Sîrbe
- 2Pediatric Discipline, Department of Mother and Child, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- 2Pediatric Clinic and Center of Expertise in Pediatric Liver Rare Disorders, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Gabriel Benţa
- 2Pediatric Discipline, Department of Mother and Child, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- 2Pediatric Clinic and Center of Expertise in Pediatric Liver Rare Disorders, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Tudor Lucian Pop
- 2Pediatric Discipline, Department of Mother and Child, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- 2Pediatric Clinic and Center of Expertise in Pediatric Liver Rare Disorders, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
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Ali RQ, Meyer-Miner A, David-Rachel M, Lee FJH, Wilkins BJ, Karpen SJ, Ciruna B, Ghanekar A, Kamath BM. Loss of zebrafish pkd1l1 causes biliary defects that have implications for biliary atresia splenic malformation. Dis Model Mech 2023; 16:dmm049326. [PMID: 37675454 PMCID: PMC10581383 DOI: 10.1242/dmm.049326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 08/15/2023] [Indexed: 09/08/2023] Open
Abstract
Biliary atresia is a fibroinflammatory neonatal disease with no effective therapies. A subset of cases (10-20%) is associated with laterality defects - labeled biliary atresia splenic malformation (BASM) syndrome. Recently, whole-exome sequencing of patients with BASM identified deleterious variants in PKD1L1. PKD1L1 is involved in left-right axis determination; however, its role in cholangiocytes is unknown. We generated the pkd1l1hsc117 allele using CRISPR/Cas9 mutagenesis in zebrafish to determine the role of Pkd1l1 in biliary development and function. Wild-type and mutant larvae were assessed for laterality defects, biliary function and biliary tree architecture at 5 days post fertilization. pkd1l1hsc117 mutant larvae exhibited early left-right patterning defects. The gallbladder was positioned on the left in 47% of mutants compared to 4% of wild-type larvae. Accumulation of PED6 in the gallbladder, an indicator of hepatobiliary function, was significantly reduced in pkd1l1hsc117 mutants (46%) compared to wild-type larvae (4%). pkd1l1hsc117 larvae exhibited fewer biliary epithelial cells and reduced density of the intrahepatic biliary network compared to those in wild-type larvae. These data highlight the essential role of pkd1l1 in normal development and function of the zebrafish biliary system, supporting a role for this gene as a cause of BASM.
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Affiliation(s)
- Rouknuddin Q. Ali
- Program in Developmental & Stem Cell Biology, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Anne Meyer-Miner
- Program in Developmental & Stem Cell Biology, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
- Department of Molecular Genetics, The University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Marie David-Rachel
- Program in Developmental & Stem Cell Biology, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
- Department of Molecular Genetics, The University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Fiona J. H. Lee
- Program in Developmental & Stem Cell Biology, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Benjamin J. Wilkins
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Saul J. Karpen
- Department of Pediatrics Emory, University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Brian Ciruna
- Program in Developmental & Stem Cell Biology, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
- Department of Molecular Genetics, The University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Anand Ghanekar
- Division of General Surgery, University Health Network, Toronto, ON M5C 2C4, Canada
- Department of Surgery, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Binita M. Kamath
- Program in Developmental & Stem Cell Biology, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON M5G 1X8, Canada
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6
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Sok P, Sabo A, Almli LM, Jenkins MM, Nembhard WN, Agopian AJ, Bamshad MJ, Blue EE, Brody LC, Brown AL, Browne ML, Canfield MA, Carmichael SL, Chong JX, Dugan-Perez S, Feldkamp ML, Finnell RH, Gibbs RA, Kay DM, Lei Y, Meng Q, Moore CA, Mullikin JC, Muzny D, Olshan AF, Pangilinan F, Reefhuis J, Romitti PA, Schraw JM, Shaw GM, Werler MM, Harpavat S, Lupo PJ. Exome-wide assessment of isolated biliary atresia: A report from the National Birth Defects Prevention Study using child-parent trios and a case-control design to identify novel rare variants. Am J Med Genet A 2023; 191:1546-1556. [PMID: 36942736 PMCID: PMC10947986 DOI: 10.1002/ajmg.a.63185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/07/2023] [Accepted: 03/07/2023] [Indexed: 03/23/2023]
Abstract
The etiology of biliary atresia (BA) is unknown, but recent studies suggest a role for rare protein-altering variants (PAVs). Exome sequencing data from the National Birth Defects Prevention Study on 54 child-parent trios, one child-mother duo, and 1513 parents of children with other birth defects were analyzed. Most (91%) cases were isolated BA. We performed (1) a trio-based analysis to identify rare de novo, homozygous, and compound heterozygous PAVs and (2) a case-control analysis using a sequence kernel-based association test to identify genes enriched with rare PAVs. While we replicated previous findings on PKD1L1, our results do not suggest that recurrent de novo PAVs play important roles in BA susceptibility. In fact, our finding in NOTCH2, a disease gene associated with Alagille syndrome, highlights the difficulty in BA diagnosis. Notably, IFRD2 has been implicated in other gastrointestinal conditions and warrants additional study. Overall, our findings strengthen the hypothesis that the etiology of BA is complex.
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Affiliation(s)
- Pagna Sok
- Pediatrics, Baylor College of Medicine, Houston, Texas,
USA
| | - Aniko Sabo
- Human Genome Sequencing Center, Baylor College of Medicine,
Houston, Texas, USA
| | - Lynn M. Almli
- National Center on Birth Defects and Developmental
Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,
USA
| | - Mary M. Jenkins
- National Center on Birth Defects and Developmental
Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,
USA
| | - Wendy N. Nembhard
- Fay W. Boozman College of Public Health, University of
Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - A. J. Agopian
- Department of Epidemiology, Human Genetics, and
Environmental Sciences, University of Texas School of Public Health, Houston, Texas,
USA
| | - Michael J. Bamshad
- Division of Genetic Medicine, Department of Pediatrics,
University of Washington, Seattle, Washington, USA
- Brotman Baty Institute for Precision Medicine, Seattle,
Washington, USA
| | - Elizabeth E. Blue
- Brotman Baty Institute for Precision Medicine, Seattle,
Washington, USA
- Division of Medical Genetics, Department of Medicine,
University of Washington, Seattle, Washington, USA
| | - Lawrence C. Brody
- Genetics and Environment Interaction Section, National
Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland,
USA
| | | | - Marilyn L. Browne
- Birth Defects Registry, New York State Department of
Health, Albany, New York, USA
- Department of Epidemiology and Biostatistics, School of
Public Health, University at Albany, Rensselaer, New York, USA
| | - Mark A. Canfield
- Birth Defects Epidemiology and Surveillance Branch, Texas
Department of State Health Services, Austin, Texas, USA
| | - Suzan L. Carmichael
- Department of Pediatrics, Stanford University School of
Medicine, Stanford, California, USA
| | - Jessica X. Chong
- Division of Genetic Medicine, Department of Pediatrics,
University of Washington, Seattle, Washington, USA
- Brotman Baty Institute for Precision Medicine, Seattle,
Washington, USA
| | - Shannon Dugan-Perez
- Human Genome Sequencing Center, Baylor College of Medicine,
Houston, Texas, USA
| | - Marcia L. Feldkamp
- Division of Medical Genetics, Department of Pediatrics,
University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Richard H. Finnell
- Department of Medicine, Center for Precision
Environmental Health, Baylor College of Medicine, Houston, Texas, USA
| | - Richard A. Gibbs
- Human Genome Sequencing Center, Baylor College of Medicine,
Houston, Texas, USA
| | - Denise M. Kay
- Division of Genetics, Wadsworth Center, New York State
Department of Health, Albany, New York, USA
| | - Yunping Lei
- Department of Medicine, Center for Precision
Environmental Health, Baylor College of Medicine, Houston, Texas, USA
| | - Qingchang Meng
- Human Genome Sequencing Center, Baylor College of Medicine,
Houston, Texas, USA
| | - Cynthia A. Moore
- National Center on Birth Defects and Developmental
Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,
USA
| | - James C. Mullikin
- Genetics and Environment Interaction Section, National
Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland,
USA
| | - Donna Muzny
- Human Genome Sequencing Center, Baylor College of Medicine,
Houston, Texas, USA
| | - Andrew F. Olshan
- Department of Epidemiology, Gillings School of Global
Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Faith Pangilinan
- Genetics and Environment Interaction Section, National
Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland,
USA
| | - Jennita Reefhuis
- National Center on Birth Defects and Developmental
Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,
USA
| | - Paul A. Romitti
- Department of Epidemiology, University of Iowa College of
Public Health, Iowa City, Iowa, USA
| | | | - Gary M. Shaw
- Department of Pediatrics, Stanford University School of
Medicine, Stanford, California, USA
| | - Martha M. Werler
- Department of Epidemiology, Boston University, Boston,
Massachusetts, USA
| | - Sanjiv Harpavat
- Pediatrics, Baylor College of Medicine, Houston, Texas,
USA
- Gastroenterology, Hepatology and Nutrition, Texas
Children’s Hospital, Houston, Texas, USA
| | - Philip J. Lupo
- Pediatrics, Baylor College of Medicine, Houston, Texas,
USA
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7
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Xie S, Wei S, Ma X, Wang R, He T, Zhang Z, Yang J, Wang J, Chang L, Jing M, Li H, Zhou X, Zhao Y. Genetic alterations and molecular mechanisms underlying hereditary intrahepatic cholestasis. Front Pharmacol 2023; 14:1173542. [PMID: 37324459 PMCID: PMC10264785 DOI: 10.3389/fphar.2023.1173542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/16/2023] [Indexed: 06/17/2023] Open
Abstract
Hereditary cholestatic liver disease caused by a class of autosomal gene mutations results in jaundice, which involves the abnormality of the synthesis, secretion, and other disorders of bile acids metabolism. Due to the existence of a variety of gene mutations, the clinical manifestations of children are also diverse. There is no unified standard for diagnosis and single detection method, which seriously hinders the development of clinical treatment. Therefore, the mutated genes of hereditary intrahepatic cholestasis were systematically described in this review.
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Affiliation(s)
- Shuying Xie
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Shizhang Wei
- Department of Anatomy, Histology and Embryology, School of Basic Medical Sciences, Health Science Center, Peking University, Beijing, China
| | - Xiao Ma
- Pharmacy College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ruilin Wang
- Department of Pharmacy, 5th Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Tingting He
- Department of Pharmacy, 5th Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhao Zhang
- Pharmacy College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ju Yang
- Pharmacy College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jiawei Wang
- Pharmacy College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lei Chang
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Manyi Jing
- Department of Pharmacy, Chinese PLA General Hospital, Beijing, China
| | - Haotian Li
- Department of Pharmacy, Chinese PLA General Hospital, Beijing, China
| | - Xuelin Zhou
- Department of Pharmacology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Yanling Zhao
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
- Department of Pharmacy, Chinese PLA General Hospital, Beijing, China
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8
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Hellen DJ, Bennett A, Malla S, Klindt C, Rao A, Dawson PA, Karpen SJ. Liver-restricted deletion of the biliary atresia candidate gene Pkd1l1 causes bile duct dysmorphogenesis and ciliopathy. Hepatology 2023; 77:1274-1286. [PMID: 36645229 DOI: 10.1097/hep.0000000000000029] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/17/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS A recent multicenter genetic exploration of the biliary atresia splenic malformation syndrome identified mutations in the ciliary gene PKD1L1 as candidate etiologic contributors. We hypothesized that deletion of Pkd1l1 in developing hepatoblasts would lead to cholangiopathy in mice. APPROACH AND RESULTS CRISPR-based genome editing inserted loxP sites flanking exon 8 of the murine Pkd1l1 gene. Pkd1l1Fl/Fl cross-bred with alpha-fetoprotein-Cre expressing mice to generate a liver-specific intrahepatic Pkd1l1 -deficient model (LKO). From embryonic day 18 through week 30, control ( Fl/Fl ) and LKO mice were evaluated with standard serum chemistries and liver histology. At select ages, tissues were analyzed using RNA sequencing, immunofluorescence, and electron microscopy with a focus on biliary structures, peribiliary inflammation, and fibrosis. Bile duct ligation for 5 days of Fl/Fl and LKO mice was followed by standard serum and liver analytics. Histological analyses from perinatal ages revealed delayed biliary maturation and reduced primary cilia, with progressive cholangiocyte proliferation, peribiliary fibroinflammation, and arterial hypertrophy evident in 7- to 16-week-old LKO versus Fl/Fl livers. Following bile duct ligation, cholangiocyte proliferation, peribiliary fibroinflammation, and necrosis were increased in LKO compared with Fl/Fl livers. CONCLUSIONS Bile duct ligation of the Pkd1l1 -deficient mouse model mirrors several aspects of the intrahepatic pathophysiology of biliary atresia in humans including bile duct dysmorphogenesis, peribiliary fibroinflammation, hepatic arteriopathy, and ciliopathy. This first genetically linked model of biliary atresia, the Pkd1l1 LKO mouse, may allow researchers a means to develop a deeper understanding of the pathophysiology of this serious and perplexing disorder, including the opportunity to identify rational therapeutic targets.
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Affiliation(s)
- Dominick J Hellen
- Division of Pediatric Gastroenterology, Department of Pediatrics, Hepatology, and Nutrition, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
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9
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Harpavat S, Hawthorne K, Setchell KDR, Rivas MN, Henn L, Beil CA, Karpen SJ, Ng VL, Alonso EM, Bezerra JA, Guthery SL, Horslen S, Loomes KM, McKiernan P, Magee JC, Merion RM, Molleston JP, Rosenthal P, Thompson RJ, Wang KS, Sokol RJ, Shneider BL. Serum bile acids as a prognostic biomarker in biliary atresia following Kasai portoenterostomy. Hepatology 2023; 77:862-873. [PMID: 36131538 PMCID: PMC9936974 DOI: 10.1002/hep.32800] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/22/2022] [Accepted: 09/04/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND AIMS In biliary atresia, serum bilirubin is commonly used to predict outcomes after Kasai portoenterostomy (KP). Infants with persistently high levels invariably need liver transplant, but those achieving normalized levels have a less certain disease course. We hypothesized that serum bile acid levels could help predict outcomes in the latter group. APPROACH AND RESULTS Participants with biliary atresia from the Childhood Liver Disease Research Network were included if they had normalized bilirubin levels 6 months after KP and stored serum samples from the 6-month post-KP clinic visit ( n = 137). Bile acids were measured from the stored serum samples and used to divide participants into ≤40 μmol/L ( n = 43) or >40 μmol/L ( n = 94) groups. At 2 years of age, the ≤40 μmol/L compared with >40 μmol/L group had significantly lower total bilirubin, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyltransferase, bile acids, and spleen size, as well as significantly higher albumin and platelet counts. Furthermore, during 734 person-years of follow-up, those in the ≤40 μmol/L group were significantly less likely to develop splenomegaly, ascites, gastrointestinal bleeding, or clinically evident portal hypertension. The ≤40 μmol/L group had a 10-year cumulative incidence of liver transplant/death of 8.5% (95% CI: 1.1%-26.1%), compared with 42.9% (95% CI: 28.6%-56.4%) for the >40 μmol/L group ( p = 0.001). CONCLUSIONS Serum bile acid levels may be a useful prognostic biomarker for infants achieving normalized bilirubin levels after KP.
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Affiliation(s)
- Sanjiv Harpavat
- Division of Gastroenterology, Department of Pediatrics , Hepatology and Nutrition, Baylor College of Medicine and Texas Children's Hospital , Houston , Texas , USA
| | - Kieran Hawthorne
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Kenneth D R Setchell
- Division of Pathology and Laboratory Medicine , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - Monica Narvaez Rivas
- Division of Pathology and Laboratory Medicine , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - Lisa Henn
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Charlotte A Beil
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Saul J Karpen
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Emory University School of Medicine , Atlanta , Georgia , USA
| | - Vicky L Ng
- Division of Gastroenterology, Hepatology and Nutrition , Hospital for Sick Children and University of Toronto , Toronto , Ontario , Canada
| | - Estella M Alonso
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Ann and Robert H. Lurie Children's Hospital of Chicago , Chicago , Illinois , USA
| | - Jorge A Bezerra
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - Stephen L Guthery
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , University of Utah , Salt Lake City , Utah , USA
| | - Simon Horslen
- Division of Gastroenterology and Hepatology, Department of Pediatrics , University of Washington Medical Center and Seattle Children's , Seattle , Washington , USA.,Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh , Pittsburgh , Pennsylvania , USA
| | - Kathy M Loomes
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Perelman School of Medicine at the University of Pennsylvania and Children's Hospital of Philadelphia , Philadelphia , Pennsylvania , USA
| | - Patrick McKiernan
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh , Pittsburgh , Pennsylvania , USA
| | - John C Magee
- Department of Surgery, Section of Transplant Surgery , University of Michigan Medical School , Ann Arbor , Michigan , USA
| | - Robert M Merion
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Jean P Molleston
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Indiana University School of Medicine and Riley Hospital for Children , Indianapolis , Indiana , USA
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , University of California San Francisco , San Francisco , California , USA
| | | | - Kasper S Wang
- Division of Pediatric Surgery, Department of Surgery , Children's Hospital of Los Angeles, University of Southern California , Los Angeles , California , USA
| | - Ronald J Sokol
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition , University of Colorado School of Medicine and Children's Hospital Colorado , Aurora , Colorado , USA
| | - Benjamin L Shneider
- Division of Gastroenterology, Department of Pediatrics , Hepatology and Nutrition, Baylor College of Medicine and Texas Children's Hospital , Houston , Texas , USA
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10
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Khan SA, Ali N, Dar FS, Malik MI. Biliary atresia-An experience from the first pediatric liver transplant center in Pakistan. Pediatr Transplant 2023; 27:e14357. [PMID: 35831918 DOI: 10.1111/petr.14357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 05/09/2022] [Accepted: 06/28/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Biliary atresia (BA) is the most common cause of neonatal cholestatic syndrome. The true incidence of BA in Pakistan is largely unknown. AIM This study aimed to report the clinical features, age at diagnosis and outcomes of biliary atresia from the first pediatric liver transplant center in Pakistan. METHODS The study was done in Shifa International hospital from 2013 to 2020. All babies who had biliary atresia confirmed by laboratory investigation were included. Demographic data, age of presentation, clinical presentation, supporting investigations like liver function tests, ultrasound abdomen, HIDA scan and liver biopsy were noted. Outcome related to Kasai portoenterostomy, liver transplant, complications and immunosuppressant agents were noted. RESULT A total of 42 children were included, 23 (54.7%) males and 19 (45.2%) were females. Jaundice was seen in all patients (100%) followed by acholic stools (81%). Associated malformations were noted in 6 (14.2%) patients. Liver function tests confirmed obstructive cholestasis (p 0.04). Kasai was done in 19 (45%) patients only, living donor liver transplant was performed in 6 (14%) patients. Age range of transplant patients was from 3 months to 1 year. Indication for liver transplant was failed Kasai in 1(16.7%) patient and chronic liver disease in 5 (83.3%) patients. LDLT survivors were 10 months to 1 year of age at the time of transplant, mean age was 10.6 months. Maximum survival noted so far is 7 years. Acute complications seen post-transplant were sepsis (three patients), surgical site infections (two patients), biliary leaks and acute cellular rejection in one patient each. Chronic graft rejection, portal vein stricture needing stenting was done in one patient. DISCUSSION All patients underwent LDLT from related donors wih no donor related mortality. All are deceased patients were yonger and had advanced disease. BA remains third most commo indication of transplant in our center. CONCLUSION Liver transplant is the only lifesaving procedure after failed Kasai or as primary liver transplant due to advance liver disease. The advent of liver transplantation services offers survival and improving outlook of the disease.
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Affiliation(s)
- Sabeen Abid Khan
- Pediatrics, Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Naurin Ali
- Pediatrics, Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Faisal Saud Dar
- Hepatobiliary Surgeon in Shifa International Hospital, Pakistan Kidney Liver Institute (PKLI), Lahore, Pakistan
| | - Munir Iqbal Malik
- Pediatric Gastroenterology, Shifa International Hospital, Shifa College of Medicine, Islamabad, Pakistan
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11
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Elebute OA, Timo MT, Alakaloko FM, Seyi-Olajide JO, Bode CO, Ademuyiwa AO. Biliary Atresia Splenic Malformation: A Case Report from A Tertiary Centre in West Africa and the Lessons Learnt. J West Afr Coll Surg 2023; 13:106-110. [PMID: 36923807 PMCID: PMC10010588 DOI: 10.4103/jwas.jwas_195_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/23/2022] [Indexed: 03/18/2023]
Abstract
Biliary atresia (BA) is a rare disease characterised by biliary obstruction of unknown origin that presents in the neonatal period. It is classified into syndromic with various congenital anomalies and non-syndromic (isolated anomaly). We present a case of syndromic BA associated with polysplenia and intestinal malrotation, discovered incidentally during the Kasai procedure. The small intestine was found to be non-rotated with the duodenojejunal junction to the right of the vertebral column. The presence of accessory spleens was noted. Kasai portoenterostomy and Ladd's procedure were performed. The patient had an uneventful postoperative course with the passage of cholic stool from the third postoperative day. At the seventh-month follow-up, the stool remained cholic. A multidisciplinary approach in the care of babies with BA and long-term follow-up is crucial for a successful outcome.
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Affiliation(s)
- Olumide A. Elebute
- Paediatric Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Manuella Talla Timo
- Paediatric Surgery Unit, Mother and Child Department, Felix Houphouet Boigny University, Abidjan, Cote D’Ivoire
| | - Felix M. Alakaloko
- Paediatric Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Justina O. Seyi-Olajide
- Paediatric Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Christopher O. Bode
- Paediatric Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Adesoji O. Ademuyiwa
- Paediatric Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
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12
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Mohamedaly S, Nijagal A. Advances in the Treatment of Neonatal Biliary Disease. Clin Perinatol 2022; 49:981-993. [PMID: 36328612 DOI: 10.1016/j.clp.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This article discusses current standard of care in neonatal biliary disease, particularly management of biliary atresia and choledochal cysts. It highlights surgical considerations, guidelines for adjuvant therapies, and promising therapeutic options that are under investigation.
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Affiliation(s)
- Sarah Mohamedaly
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, 513 Parnassus Avenue, HSW 1652, Campus Box 0570, San Francisco, CA 94143-0570, USA
| | - Amar Nijagal
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, 513 Parnassus Avenue, HSW 1652, Campus Box 0570, San Francisco, CA 94143-0570, USA; The Liver Center, University of California, San Francisco, CA, USA; The Pediatric Liver Center at UCSF Benioff Childrens' Hospitals, San Francisco, CA, USA.
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13
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Zope M, Esparaz J, Alemayehu H, Martin C. Rare case report of closing gastroschisis with an absent common bile duct. Journal of Pediatric Surgery Case Reports 2022. [DOI: 10.1016/j.epsc.2022.102339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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14
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Rosa JA, Pinto AMR, Del Bigio JZ, Lima LB, Silva MMD, Mano RBC, Falcão MC. Omphalocele and biliary atresia: chance or causality. A case report. einstein (São Paulo) 2022; 20:eRC0072. [PMID: 36169552 PMCID: PMC9491385 DOI: 10.31744/einstein_journal/2022rc0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/20/2022] [Indexed: 11/12/2022] Open
Abstract
To relate omphalocele and biliary atresia and investigate possible embryological correlations that justify the simultaneous occurrence. A female preterm newborn diagnosed as omphalocele; cesarean delivery, weight 2,500g, 46 XX karyotype. Initially, the newborn remained fasting and on parenteral nutrition, and enteral diet was introduced later, with good acceptance. On the 12th day of life, the newborn presented direct hyperbilirubinemia, increased levels of liver enzymes and fecal acholia, with a presumptive diagnosis of biliary atresia. However, the ultrasound was inconclusive, due to anatomical changes resulting from omphalocele. A surgical approach was chosen on the 37th day of life aiming to confirm diagnosis of biliary atresia and to repair omphalocele. During the surgical procedure, structural alterations compatible with biliary atresia were observed, later confirmed by pathological examination; a hepatoportoenterostomy was performed and the omphalocele was corrected. She evolved well in the postoperative period, with a decrease in direct bilirubin and liver enzymes, as well as resolution of fecal acholia, and was discharged in good clinical condition. This is a bizarre and extremely rare association, but the prognosis may be good when an early diagnosis is made and surgery performed, besides support and clinical management to prevent complications in the perioperative period. Although the pathogenesis of the diseases has not been fully defined yet, there is, to date, no direct relation between them. The association between omphalocele and biliary atresia is extremely uncommon, with only two published cases.
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15
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Jeon TY. [Overview of Biliary Atresia]. J Korean Soc Radiol 2022; 83:979-990. [PMID: 36276222 PMCID: PMC9574279 DOI: 10.3348/jksr.2022.0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/07/2022] [Accepted: 09/10/2022] [Indexed: 11/15/2022]
Abstract
Biliary atresia is a progressive, idiopathic, obliterative disease of the extrahepatic biliary tree that presents with biliary obstruction in the neonatal period. It is the most common indication for liver transplantation in children. If untreated, progressive liver cirrhosis leads to death by two years of age. Nowadays, more than 90% of biliary atresia patients survive into adulthood with the development of Kasai portoenterostomy and liver transplantation technology. Early diagnosis is critical since the success rate of the Kasai portoenterostomy decreases with time. This study comprehensively reviews the recent advances in the etiology, classification, prevalence, clinical manifestations, treatment, and prognosis of biliary atresia.
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16
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Abstract
Biliary atresia is a rare disease but remains the most common indication for pediatric liver transplantation as there are no effective medical therapies to slow progression after diagnosis. Variable contribution of genetic, immune, and environmental factors contributes to disease heterogeneity among patients with biliary atresia. Developing a deeper understanding of the disease mechanism will help to develop targeted medical therapies and improve patient outcomes.
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Affiliation(s)
- Swati Antala
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann and Robert H Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Sarah A. Taylor
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann and Robert H Lurie Children’s Hospital of Chicago, Chicago, IL, USA
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17
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Khoei S, Samani PR, Fazelnia F, Pak N. Cholecysto-hepatic duct serving as the only drainage pathway of bile from the intrahepatic to the extrahepatic biliary system in an infant: a case report. BMC Pediatr 2022; 22:438. [PMID: 35864479 PMCID: PMC9306022 DOI: 10.1186/s12887-022-03491-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 07/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background Cholecystohepatic duct is a rare anomaly of the biliary system which involves drainage of bile into the gallbladder which may be associated with agenesis of the common hepatic duct or common bile duct. Case presentation A 2.5-month-old infant presented to our emergency department with icterus. He had a history of esophageal atresia and imperforate anus which had been treated surgically by thoracotomy, esophagostomy, gastrostomy and colostomy placement. Following imaging studies by ultrasound and MRCP, the diagnosis of common hepatic duct agenesis was made. Cholecystohepatic duct was present as the solitary drainage pathway of bile from the intrahepatic to extrahepatic biliary system. Conclusions Cholecystohepatic ducts need a high index of suspicion to be diagnosed on preoperative hepatobiliary imaging. As they may be asymptomatic, they are predisposed to iatrogenic injury during hepatobiliary surgeries.
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Affiliation(s)
- Samin Khoei
- Radiology resident, Imam Khomeini hospital complex, Tehran university of medical sciences, Tehran, Iran
| | - Payam Riahi Samani
- Radiology resident, Imam Khomeini hospital complex, Tehran university of medical sciences, Tehran, Iran
| | - Faezeh Fazelnia
- Radiology resident, Shariati hospital, Tehran university of medical sciences, Tehran, Iran
| | - Neda Pak
- Neda Pak, associate professor of radiology, children medical center of excellence, Tehran university of medical sciences (TUMS), Tehran, Iran.
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18
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Cavallo L, Kovar EM, Aqul A, McLoughlin L, Mittal NK, Rodriguez-Baez N, Shneider BL, Zwiener RJ, Chambers TM, Langlois PH, Canfield MA, Agopian AJ, Lupo PJ, Harpavat S. The Epidemiology of Biliary Atresia: Exploring the Role of Developmental Factors on Birth Prevalence. J Pediatr 2022; 246:89-94.e2. [PMID: 35364097 PMCID: PMC9332904 DOI: 10.1016/j.jpeds.2022.03.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/04/2022] [Accepted: 03/24/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To identify key epidemiologic factors relevant to fetal development that are associated with biliary atresia. STUDY DESIGN This population-based registry study examined infants born in Texas between 1999 and 2014. Epidemiologic data relevant to fetal development were compared between cases of biliary atresia identified in the Texas Birth Defects Registry (n = 305) vs all live births (n = 4 689 920), and Poisson regression was used to calculate prevalence ratios (PRs) and 95% CIs. RESULTS The prevalence of biliary atresia over the study period was 0.65 per 10 000 live births. Biliary atresia was positively associated with female sex (adjusted PR, 1.68; 95% CI, 1.33-2.12), delivery before 32-37 weeks of gestation (adjusted PR, 1.64; 95% CI, 1.18-2.29), delivery before 32 weeks of gestation (adjusted PR, 3.85; 95% CI, 2.38-6.22), and non-Hispanic Black vs non-Hispanic White maternal race/ethnicity (adjusted PR, 1.54, 95% CI, 1.06-2.24), while biliary atresia was inversely associated with season of conception in the fall relative to spring (adjusted PR, 0.62; 95% CI, 0.45-0.86). In addition, biliary atresia was associated with maternal diabetes (adjusted PR, 2.34; 95% CI, 1.57-3.48), with a stronger association with pregestational diabetes compared with gestational diabetes. In subgroup analyses, these associations were present in isolated biliary atresia cases that do not have any additional birth defects. CONCLUSIONS Biliary atresia is associated with multiple factors related to fetal development, including pregestational maternal diabetes, female sex, and preterm birth. These associations also were observed in isolated cases of biliary atresia without other malformations or laterality defects. Our results are consistent with early life events influencing the pathogenesis of biliary atresia, and support further studies investigating in utero events to better understand etiology and time of onset.
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Affiliation(s)
- Laurel Cavallo
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine/Texas Children’s Hospital, Houston, TX
| | - Erin M. Kovar
- Division of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Amal Aqul
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Naveen K. Mittal
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Norberto Rodriguez-Baez
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Benjamin L. Shneider
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine/Texas Children’s Hospital, Houston, TX
| | | | - Tiffany M. Chambers
- Division of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | | | - Mark A. Canfield
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, TX
| | - A. J. Agopian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas School of Public Health, Houston, TX
| | - Philip J. Lupo
- Division of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Sanjiv Harpavat
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX.
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19
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Brahee DD, Lampl BS. Neonatal diagnosis of biliary atresia: a practical review and update. Pediatr Radiol 2022; 52:685-692. [PMID: 34331566 DOI: 10.1007/s00247-021-05148-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/03/2021] [Accepted: 06/28/2021] [Indexed: 02/02/2023]
Abstract
Biliary atresia is challenging to diagnose because many of the clinical and imaging features of this condition overlap with those of other causes of cholestasis in newborns. When jaundice persists beyond 2 weeks of age, the neonate should be evaluated for cholestasis, and biliary atresia - the most common cause of neonatal cholestasis - should be considered. It is critical to diagnose biliary atresia early because failure to treat can result in hepatic fibrosis and death in less than 1 year. In this paper, we review the current diagnostic imaging methods, differential considerations and treatment options for biliary atresia.
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Affiliation(s)
- Deborah D Brahee
- Department of Radiology, Cleveland Clinic, 9500 Euclid Ave., Mail Code L10, Cleveland, OH, 44193, USA.
| | - Brooke S Lampl
- Department of Radiology, Cleveland Clinic, 9500 Euclid Ave., Mail Code L10, Cleveland, OH, 44193, USA
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20
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Montoya-Cerrillo D, Bernieh A, Saad AG. Critical diagnoses in paediatric gastrointestinal diseases. Pathology 2022; 54:195-206. [PMID: 35033374 DOI: 10.1016/j.pathol.2021.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/26/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022]
Abstract
Gastrointestinal biopsies represent an increasing proportion of the paediatric pathologist's workload, an increase fundamentally due to an expansion of the understanding of the basic clinical, molecular, genetic, and histopathological features of paediatric gastrointestinal disorders. The histological interpretation of endoscopically retrieved gastrointestinal biopsies in children requires a unique set of diagnostic expertise and detailed knowledge of various gastrointestinal disorders that have a predilection for the paediatric population. This article's major role is to highlight the unique problems inherent to paediatric gastrointestinal disorders that require immediate communication with the paediatric surgeon or the gastroenterologist. For this, we tried to cover the most important diseases that a paediatric pathologist might encounter in daily practice. Some of these diseases are relatively rare, such as microvillous inclusion disease and tufting enteropathy, but some are more common such as eosinophilic disorders and inflammatory bowel disease. Awareness of the histopathological features of these diseases, particularly those that are relatively uncommon, is crucial to spare the patient a lengthy and costly evaluation. We made a particular effort to abundantly reference this article should the reader wish to expand on the content of any section.
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Affiliation(s)
| | - Anas Bernieh
- Division of Pathology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Ali G Saad
- Department of Pathology, University of Miami Miller School of Medicine, Miami, FL, USA.
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21
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Quelhas P, Cerski C, Dos Santos JL. Update on Etiology and Pathogenesis of Biliary Atresia. Curr Pediatr Rev 2022; 19:48-67. [PMID: 35538816 DOI: 10.2174/1573396318666220510130259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/16/2022] [Accepted: 02/15/2022] [Indexed: 01/31/2023]
Abstract
Biliary atresia is a rare inflammatory sclerosing obstructive cholangiopathy that initiates in infancy as complete choledochal blockage and progresses to the involvement of intrahepatic biliary epithelium. Growing evidence shows that biliary atresia is not a single entity with a single etiology but a phenotype resulting from multifactorial events whose common path is obliterative cholangiopathy. The etiology of biliary atresia has been explained as resulting from genetic variants, toxins, viral infection, chronic inflammation or bile duct lesions mediated by autoimmunity, abnormalities in the development of the bile ducts, and defects in embryogenesis, abnormal fetal or prenatal circulation and susceptibility factors. It is increasingly evident that the genetic and epigenetic predisposition combined with the environmental factors to which the mother is exposed are potential triggers for biliary atresia. There is also an indication that a progressive thickening of the arterial middle layer occurs in this disease, suggestive of vascular remodeling and disappearance of the interlobular bile ducts. It is suggested that the hypoxia/ischemia process can affect portal structures in biliary atresia and is associated with both the extent of biliary proliferation and the thickening of the medial layer.
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Affiliation(s)
- Patrícia Quelhas
- CICS-UBI - Centro de Investigação em Ciências da Saúde, University of Beira Interior, 6200-506 Covilhã, Portugal
| | - Carlos Cerski
- Department of Pathology, University Federal Rio Grande do Sul, 90040-060, Porto Alegre, Brasil
| | - Jorge Luiz Dos Santos
- CICS-UBI - Centro de Investigação em Ciências da Saúde, University of Beira Interior, 6200-506 Covilhã, Portugal
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22
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Amarachintha SP, Mourya R, Ayabe H, Yang L, Luo Z, Li X, Thanekar U, Shivakumar P, Bezerra JA. Biliary organoids uncover delayed epithelial development and barrier function in biliary atresia. Hepatology 2022; 75:89-103. [PMID: 34392560 PMCID: PMC9983428 DOI: 10.1002/hep.32107] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 07/09/2021] [Accepted: 07/31/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Biliary atresia is a severe inflammatory and fibrosing cholangiopathy of neonates of unknown etiology. The onset of cholestasis at birth implies a prenatal onset of liver dysfunction. Our aim was to investigate the mechanisms linked to abnormal cholangiocyte development. APPROACH AND RESULTS We generated biliary organoids from liver biopsies of infants with biliary atresia and normal and diseased controls. Organoids emerged from biliary atresia livers and controls and grew as lumen-containing spheres with an epithelial lining of cytokeratin-19pos albuminneg SOX17neg cholangiocyte-like cells. Spheres had similar gross morphology in all three groups and expressed cholangiocyte-enriched genes. In biliary atresia, cholangiocyte-like cells lacked a basal positioning of the nucleus, expressed fewer developmental and functional markers, and displayed misorientation of cilia. They aberrantly expressed F-actin, β-catenin, and Ezrin, had low signals for the tight junction protein zonula occludens-1 (ZO-1), and displayed increased permeability as evidenced by a higher Rhodamine-123 (R123) signal inside organoids after verapamil treatment. Biliary atresia organoids had decreased expression of genes related to EGF signaling and FGF2 signaling. When treated with EGF+FGF2, biliary atresia organoids expressed differentiation (cytokeratin 7 and hepatocyte nuclear factor 1 homeobox B) and functional (somatostatin receptor 2, cystic fibrosis transmembrane conductance regulator [CFTR], aquaporin 1) markers, restored polarity with improved localization of F-actin, β-catenin and ZO-1, increased CFTR function, and decreased uptake of R123. CONCLUSIONS Organoids from biliary atresia are viable and have evidence of halted epithelial development. The induction of developmental markers, improved cell-cell junction, and decreased epithelial permeability by EGF and FGF2 identifies potential strategies to promote epithelial maturation and function.
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Affiliation(s)
- Surya P. Amarachintha
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Reena Mourya
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Hiroaki Ayabe
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Li Yang
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Zhenhua Luo
- Institute of Precision Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiaofeng Li
- Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Unmesha Thanekar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Pranavkumar Shivakumar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jorge A. Bezerra
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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23
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Wu X, Su L, Shen Q, Guo Q, Li Y, Xu S, Lin N, Huang H, Xu L. Chromosomal Abnormalities and Pregnancy Outcomes for Fetuses With Gastrointestinal Tract Obstructions. Front Pediatr 2022; 10:918130. [PMID: 35783302 PMCID: PMC9245709 DOI: 10.3389/fped.2022.918130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/09/2022] [Indexed: 11/23/2022] Open
Abstract
Fetal gastrointestinal tract obstruction (GITO) is the most frequently encountered gastrointestinal defect in the prenatal period. This study aimed to investigate the genetic disorders and pregnancy outcomes of fetal GITO. We reviewed data from 70 pregnancies that were referred for invasive prenatal testing because of fetal GITO. According to the level of obstruction, they were classified into esophageal atresia/stenosis, duodenal atresia/stenosis, jejunal or ileal atresia/stenosis, or anal atresia. Traditional karyotyping was performed on all the 70 pregnancies, and chromosomal microarray analysis (CMA) was performed on 32 of them in parallel. Traditional karyotyping revealed twelve (17.1%) chromosomal abnormalities, including 11 cases of trisomy 21 (Down syndrome), and one case of a supernumerary marker chromosome related to Cat eye syndrome. According to the absence or presence of other ultrasound anomalies, they were categorized into isolated GITO (n = 36) and non-isolated GITO (n = 34). The rate of chromosomal abnormalities in the non-isolated GITO pregnancies was significantly higher than that in the isolated GITO pregnancies (29.4 vs. 5.5%, p < 0.05); the survival rate in the isolated group was significantly higher than that in the non-isolated group (67.6 vs. 34.4%, p < 0.05). Among the 32 cases where CMA was performed, an additional one (3.1%) copy number variant with clinical significance was noted in a fetus with normal karyotype. The microduplication on 7q12 was considered to be the genetic etiology of duodenal stenosis, although it was inherited from a phenotypically normal mother. Our study supports the strong association between Down syndrome and fetal GITO, especially duodenal stenosis. Our findings suggested that the risk of chromosomal abnormalities was increased when GITO was accompanied by other ultrasound anomalies; thus, chromosomal abnormalities and fetal anatomy should be carefully evaluated for pregnancy management of fetal GITO.
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Affiliation(s)
- Xiaoqing Wu
- Department of Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.,Fujian Provincial Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China.,Department of Laboratory Medicine, Fujian Medical University, Fuzhou, China
| | - Linjuan Su
- Department of Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.,Fujian Provincial Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China
| | - Qingmei Shen
- Department of Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.,Fujian Provincial Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China
| | - Qun Guo
- Department of Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.,Fujian Provincial Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China
| | - Ying Li
- Department of Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.,Fujian Provincial Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China
| | - Shiyi Xu
- Department of Pediatrics, Guangxi Medical University, Nanning, China
| | - Na Lin
- Medical Genetic Diagnosis and Therapy Center of Fujian Provincial Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Hailong Huang
- Department of Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.,Fujian Provincial Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China
| | - Liangpu Xu
- Department of Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.,Fujian Provincial Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, China
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24
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Ranucci G, Della Corte C, Alberti D, Bondioni MP, Boroni G, Calvo PL, Cananzi M, Candusso M, Clemente MG, D'Antiga L, Degrassi I, De Ville De Goyet J, Di Dato F, Di Giorgio A, Vici CD, Ferrari F, Francalanci P, Fuoti M, Fusaro F, Gaio P, Grimaldi C, Iascone M, Indolfi G, Iorio R, Maggiore G, Mandato C, Matarazzo L, Monti L, Mosca F, Nebbia G, Nuti F, Paolella G, Pinon M, Roggero P, Sciveres M, Serranti D, Spada M, Vajro P, Nicastro E. Diagnostic approach to neonatal and infantile cholestasis: A position paper by the SIGENP liver disease working group. Dig Liver Dis 2022; 54:40-53. [PMID: 34688573 DOI: 10.1016/j.dld.2021.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/23/2021] [Accepted: 09/12/2021] [Indexed: 12/11/2022]
Abstract
Neonatal and infantile cholestasis (NIC) can represent the onset of a surgically correctable disease and of a genetic or metabolic disorder worthy of medical treatment. Timely recognition of NIC and identification of the underlying etiology are paramount to improve outcomes. Upon invitation by the Italian National Institute of Health (ISS), an expert working grouped was formed to formulate evidence-based positions on current knowledge about the diagnosis of NIC. A systematic literature search was conducted to collect evidence about epidemiology, etiology, clinical aspects and accuracy of available diagnostic tests in NIC. Evidence was scored using the GRADE system. All recommendations were approved by a panel of experts upon agreement of at least 75% of the members. The final document was approved by all the panel components. This position document summarizes the collected statements and defines the best-evidence diagnostic approach to cholestasis in the first year of life.
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Affiliation(s)
- Giusy Ranucci
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital AORN, Naples, Italy
| | - Claudia Della Corte
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Maria Pia Bondioni
- Pediatric Radiology, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | | | - Pier Luigi Calvo
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliera-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Mara Cananzi
- Unit of Gastroenterology, Digestive Endoscopy, Hepatology and Care of Children with Liver Transplantation, University Hospital of Padova, Padova, Italy
| | - Manila Candusso
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maria Grazia Clemente
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Lorenzo D'Antiga
- Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Irene Degrassi
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jean De Ville De Goyet
- Pediatric Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, ISMETT UPMC, Palermo, Italy
| | - Fabiola Di Dato
- Department di Translational Medical Science, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Angelo Di Giorgio
- Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Carlo Dionisi Vici
- Division of Metabolism and Metabolic Diseases Research Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Paola Francalanci
- Department of Pathology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maurizio Fuoti
- Pediatric Gastroenterology and Endoscopy Unit Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Fabio Fusaro
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Paola Gaio
- Unit of Gastroenterology, Digestive Endoscopy, Hepatology and Care of Children with Liver Transplantation, University Hospital of Padova, Padova, Italy
| | - Chiara Grimaldi
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maria Iascone
- Medical Genetics Laboratory, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Indolfi
- Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Raffaele Iorio
- Department di Translational Medical Science, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giuseppe Maggiore
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Claudia Mandato
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital AORN, Naples, Italy
| | | | - Lidia Monti
- Department of Radiology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gabriella Nebbia
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Nuti
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Paolella
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michele Pinon
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliera-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Paola Roggero
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Sciveres
- Pediatric Hepatology and Liver Transplantation, ISMETT UPMC, Palermo, Italy
| | - Daniele Serranti
- Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Pietro Vajro
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana" University of Salerno, Baronissi, Italy
| | - Emanuele Nicastro
- Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
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25
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Ningappa M, Adenuga M, Ngo KA, Mohamed N, Narayanan T, Prasadan K, Ashokkumar C, Das J, Schmitt L, Hartman H, Sehrawat A, Salgado CM, Reyes-Mugica M, Gittes GK, Lo CW, Subramaniam S, Sindhi R. Mechanisms of Impaired Lung Development and Ciliation in Mannosidase-1-Alpha-2 ( Man1a2) Mutants. Front Physiol 2021; 12:658518. [PMID: 34366878 PMCID: PMC8343402 DOI: 10.3389/fphys.2021.658518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 06/03/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Ciliary defects cause heterogenous phenotypes related to mutation burden which lead to impaired development. A previously reported homozygous deletion in the Man1a2 gene causes lethal respiratory failure in newborn pups and decreased lung ciliation compared with wild type (WT) pups. The effects of heterozygous mutation, and the potential for rescue are not known. PURPOSE We hypothesized that survival and lung ciliation, (a) would decrease progressively in Man1a2 +/- heterozygous and Man1a2 -/- null newborn pups compared with WT, and (b) could be enhanced by gestational treatment with N-Acetyl-cysteine (NAC), an antioxidant. METHODS Man1a2+/- adult mice were fed NAC or placebo from a week before breeding through gestation. Survival of newborn pups was monitored for 24 h. Lungs, liver and tails were harvested for morphology, genotyping, and transcriptional profiling. RESULTS Survival (p = 0.0001, Kaplan-Meier) and percent lung ciliation (p = 0.0001, ANOVA) measured by frequency of Arl13b+ respiratory epithelial cells decreased progressively, as hypothesized. Compared with placebo, gestational NAC treatment enhanced (a) lung ciliation in pups with each genotype, (b) survival in heterozygous pups (p = 0.017) but not in WT or null pups. Whole transcriptome of lung but not liver demonstrated patterns of up- and down-regulated genes that were identical in living heterozygous and WT pups, and completely opposite to those in dead heterozygous and null pups. Systems biology analysis enabled reconstruction of protein interaction networks that yielded functionally relevant modules and their interactions. In these networks, the mutant Man1a2 enzyme contributes to abnormal synthesis of proteins essential for lung development. The associated unfolded protein, hypoxic and oxidative stress responses can be mitigated with NAC. Comparisons with the developing human fetal lung transcriptome show that NAC likely restores normal vascular and epithelial tube morphogenesis in Man1a2 mutant mice. CONCLUSION Survival and lung ciliation in the Man1a2 mutant mouse, and its improvement with N-Acetyl cysteine is genotype-dependent. NAC-mediated rescue depends on the central role for oxidative and hypoxic stress in regulating ciliary function and organogenesis during development.
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Affiliation(s)
- Mylarappa Ningappa
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - Morayooluwa Adenuga
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - Kim A. Ngo
- Department of Bioengineering, University of California, San Diego, San Diego, La Jolla, CA, United States
| | - Nada Mohamed
- Division of Pediatric General and Thoracic Surgery, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Tejaswini Narayanan
- Department of Bioengineering, University of California, San Diego, San Diego, La Jolla, CA, United States
| | - Krishna Prasadan
- Rangos Research Center Animal Imaging Core, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Chethan Ashokkumar
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - Jishnu Das
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
- Departments of Immunology and Computational and Systems Biology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Lori Schmitt
- Histology Core Laboratory Manager, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Hannah Hartman
- Division of Pediatric General and Thoracic Surgery, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Anuradha Sehrawat
- Division of Pediatric General and Thoracic Surgery, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Claudia M. Salgado
- Division of Pediatric Pathology, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Miguel Reyes-Mugica
- Division of Pediatric Pathology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - George K. Gittes
- Surgeon-in-Chief Emeritus, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Cecilia W. Lo
- Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Shankar Subramaniam
- Department of Bioengineering, University of California, San Diego, San Diego, La Jolla, CA, United States
- Department of Cellular and Molecular Medicine, University of California, San Diego, San Diego, La Jolla, CA, United States
- Department of Computer Science and Engineering, and Nanoengineering, University of California, San Diego, San Diego, La Jolla, CA, United States
| | - Rakesh Sindhi
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
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26
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Napolitano M, Franchi-Abella S, Damasio BM, Augdal TA, Avni FE, Bruno C, Darge K, Ključevšek D, Littooij AS, Lobo L, Mentzel HJ, Riccabona M, Stafrace S, Toso S, Woźniak MM, Di Leo G, Sardanelli F, Ording Müller LS, Petit P. Practical approach for the diagnosis of biliary atresia on imaging, part 2: magnetic resonance cholecystopancreatography, hepatobiliary scintigraphy, percutaneous cholecysto-cholangiography, endoscopic retrograde cholangiopancreatography, percutaneous liver biopsy, risk scores and decisional flowchart. Pediatr Radiol 2021; 51:1545-54. [PMID: 33974103 DOI: 10.1007/s00247-021-05034-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/23/2020] [Accepted: 02/21/2021] [Indexed: 12/11/2022]
Abstract
We aim to present a practical approach to imaging in suspected biliary atresia, an inflammatory cholangiopathy of infancy resulting in progressive fibrosis and obliteration of extrahepatic and intrahepatic bile ducts. Left untreated or with failure of the Kasai procedure, biliary atresia progresses to biliary cirrhosis, end-stage liver failure and death within the first years of life. Differentiating biliary atresia from other nonsurgical causes of neonatal cholestasis is difficult as there is no single method for diagnosing biliary atresia and clinical, laboratory and imaging features of this disease overlap with those of other causes of neonatal cholestasis. In this second part, we discuss the roles of magnetic resonance (MR) cholecystopancreatography, hepatobiliary scintigraphy, percutaneous biopsy and percutaneous cholecysto-cholangiography. Among imaging techniques, ultrasound (US) signs have a high specificity, although a normal US examination does not rule out biliary atresia. Other imaging techniques with direct opacification of the biliary tree combined with percutaneous liver biopsy have roles in equivocal cases. MR cholecystopancreatography and hepatobiliary scintigraphy are not useful for the diagnosis of biliary atresia. We propose a decisional flowchart for biliary atresia diagnosis based on US signs, including elastography, percutaneous cholecysto-cholangiography or endoscopic retrograde cholangiopancreatography and liver biopsy.
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27
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Hartmann P, Carter R, Keller B, Saenz NC, Schwarz KB. Complete Absence of the Extrahepatic Biliary Tree in a Newborn With Pigmented Stools. Pediatrics 2021; 148:peds.2020-038596. [PMID: 34398808 DOI: 10.1542/peds.2020-038596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 11/24/2022] Open
Abstract
"Yellow stools in neonatal cholestasis exclude biliary atresia." This conventional wisdom led to the development of the infant stool color card, which alerts parents to seek medical referral when pale stools are observed, a strategy that has been shown to improve survival in infants with biliary atresia (BA). Here, we present a case of a newborn with significant direct hyperbilirubinemia (direct bilirubin level of up to 9.2 mg/dL on day of life 10) who continued to produce colored stools. Whole-genome sequencing results were negative for genetic causes of cholestasis. Hepatobiliary scintigraphy findings were nonexcretory. A liver biopsy specimen revealed cholestasis, ductular hyperplasia, giant cell formation, minimal inflammation, minimal portal or periportal fibrosis, and no evidence of viral changes. On day of life 38, during the exploratory laparotomy, the patient was found to have complete absence of the extrahepatic biliary tree, or biliary aplasia, possibly a rare, severe form of BA. This report aims to increase our vigilance and help prevent diagnostic error in patients with signs and symptoms of BA who may produce pigmented stools. Primary care physicians should hence refer an infant (early and urgently) to a pediatric gastroenterologist for further workup for a direct bilirubin level >1.0 mg/dL with any total bilirubin level, irrespective of the color of the infant's stools.
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Affiliation(s)
- Phillipp Hartmann
- Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics
| | | | - Benjamin Keller
- Division of Pediatric Surgery, Department of Surgery, University of California, San Diego, La Jolla, California
| | - Nicholas C Saenz
- Division of Pediatric Surgery, Department of Surgery, University of California, San Diego, La Jolla, California
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28
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Abstract
OBJECTIVES To describe the clinical, histopathologic, and outcomes data for a cohort of patients with biliary atresia (BA), and to identify the factors affecting survival. METHODS This was a cross-sectional study of all BA patients diagnosed between 1999 and 2017. Clinical, biochemical, imaging, and histopathologic data were analyzed, and Kaplan-Meier survival rates were compared to identify potential prognostic factors. RESULTS We evaluated 23 patients. The median age at the Kasai procedure was 77 ± 34 days, and the median overall survival was 12.5 ± 65 months. Thirteen (56%) patients survived with their native livers, 3 (13%) received a transplant, and 6 died (26%) while awaiting a transplant. Cholangitis and the use of ursodeoxycholic acid were associated with longer survival, while impaired synthetic function was associated with shorter survival. CONCLUSIONS Most patients presented late for the Kasai procedure. The survival rate with the native liver was comparable to other cohorts. Therefore, clinicians are encouraged to refer for the Kasai procedure even with late presentation (between 60 and 90 days), provided there is no hepatic decompensation.
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Affiliation(s)
- Ammar Khayat
- Department of Pediatrics, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia.,Pediatric Gastroenterology Unit, Department of Pediatrics, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Aisha M Alamri
- Department of Pediatrics, East Jeddah General Hospital, Jeddah, Saudi Arabia
| | - Omar I Saadah
- Pediatric Gastroenterology Unit, Department of Pediatrics, King Abdulaziz University Hospital, Jeddah, Saudi Arabia.,Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Gijbels E, Pieters A, De Muynck K, Vinken M, Devisscher L. Rodent models of cholestatic liver disease: A practical guide for translational research. Liver Int 2021; 41:656-682. [PMID: 33486884 PMCID: PMC8048655 DOI: 10.1111/liv.14800] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 01/08/2021] [Accepted: 01/15/2021] [Indexed: 12/12/2022]
Abstract
Cholestatic liver disease denotes any situation associated with impaired bile flow concomitant with a noxious bile acid accumulation in the liver and/or systemic circulation. Cholestatic liver disease can be subdivided into different types according to its clinical phenotype, such as biliary atresia, drug-induced cholestasis, gallstone liver disease, intrahepatic cholestasis of pregnancy, primary biliary cholangitis and primary sclerosing cholangitis. Considerable effort has been devoted to elucidating underlying mechanisms of cholestatic liver injuries and explore novel therapeutic and diagnostic strategies using animal models. Animal models employed according to their appropriate applicability domain herein play a crucial role. This review provides an overview of currently available in vivo animal models, fit-for-purpose in modelling different types of cholestatic liver diseases. Moreover, a practical guide and workflow is provided which can be used for translational research purposes, including all advantages and disadvantages of currently available in vivo animal models.
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Affiliation(s)
- Eva Gijbels
- Department of In Vitro Toxicology and Dermato‐CosmetologyVrije Universiteit BrusselBrusselsBelgium,Gut‐Liver Immunopharmacology Unit, Basic and Applied Medical SciencesLiver Research Center GhentFaculty of Medicine and Health SciencesGhent UniversityGhentBelgium
| | - Alanah Pieters
- Department of In Vitro Toxicology and Dermato‐CosmetologyVrije Universiteit BrusselBrusselsBelgium
| | - Kevin De Muynck
- Gut‐Liver Immunopharmacology Unit, Basic and Applied Medical SciencesLiver Research Center GhentFaculty of Medicine and Health SciencesGhent UniversityGhentBelgium,Hepatology Research UnitInternal Medicine and PaediatricsLiver Research Center GhentFaculty of Medicine and Health SciencesGhent UniversityGhentBelgium
| | - Mathieu Vinken
- Department of In Vitro Toxicology and Dermato‐CosmetologyVrije Universiteit BrusselBrusselsBelgium
| | - Lindsey Devisscher
- Gut‐Liver Immunopharmacology Unit, Basic and Applied Medical SciencesLiver Research Center GhentFaculty of Medicine and Health SciencesGhent UniversityGhentBelgium
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Napolitano M, Franchi-Abella S, Damasio MB, Augdal TA, Avni FE, Bruno C, Darge K, Ključevšek D, Littooij AS, Lobo L, Mentzel HJ, Riccabona M, Stafrace S, Toso S, Woźniak MM, Di Leo G, Sardanelli F, Ording Müller LS, Petit P. Practical approach to imaging diagnosis of biliary atresia, Part 1: prenatal ultrasound and magnetic resonance imaging, and postnatal ultrasound. Pediatr Radiol 2021; 51:314-31. [PMID: 33201318 DOI: 10.1007/s00247-020-04840-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/16/2020] [Accepted: 09/07/2020] [Indexed: 12/27/2022]
Abstract
We present a practical approach to imaging in suspected biliary atresia, an inflammatory cholangiopathy of infancy resulting in progressive fibrosis and obliteration of extrahepatic and intrahepatic bile ducts. Left untreated or with failure of the Kasai procedure, biliary atresia progresses towards biliary cirrhosis, end-stage liver failure and death by age 3. Differentiation of biliary atresia from other nonsurgical causes of neonatal cholestasis is challenging because there is no single method for diagnosing biliary atresia, and clinical, laboratory and imaging features of this disease overlap with those of other causes of neonatal cholestasis. Concerning imaging, our systematic literature review shows that ultrasonography is the main tool for pre- and neonatal diagnosis. Key prenatal features, when present, are non-visualisation of the gallbladder, cyst in the liver hilum, heterotaxy syndrome and irregular gallbladder walls. Postnatal imaging features have a very high specificity when present, but a variable sensitivity. Triangular cord sign and abnormal gallbladder have the highest sensitivity and specificity. The presence of macro- or microcyst or polysplenia syndrome is highly specific but less sensitive. The diameter of the hepatic artery and hepatic subcapsular flow are less reliable. When present in the context of acholic stools, dilated intrahepatic bile ducts rule out biliary atresia. Importantly, a normal US exam does not rule out biliary atresia. Signs of chronic hepatopathy and portal hypertension (portosystemic derivations such as patent ductus venosus, recanalised umbilical vein, splenomegaly and ascites) should be actively identified for - but are not specific for - biliary atresia.
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31
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Aldeiri B, Giamouris V, Pushparajah K, Miller O, Baker A, Davenport M. Cardiac-associated biliary atresia (CABA): a prognostic subgroup. Arch Dis Child 2021; 106:68-72. [PMID: 32690577 DOI: 10.1136/archdischild-2020-319122] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/13/2020] [Accepted: 06/15/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To describe the range of concurrent cardiac malformations in biliary atresia (BA) while providing a functional framework of risk. METHODS Demographic and variables were collected from a prospectively maintained single-centre database. Infants were grouped according to a cardiac functional framework (A=acyanotic, B=cyanotic and C=insignificant shunt). Primary outcome was set as clearance of jaundice (bilirubin ≤20 μmol/L) following Kasai portoenterostomy (KPE). Native liver survival and overall actuarial survival were compared with a date-matched control infant with BA (n=77). P value <0.05 was regarded as significant. RESULTS 524 infants with histologically confirmed BA were treated between January 1999 and December 2018, 37 (7%) had a concurrent cardiac anomaly (A: n=23 (62%), B: n=10 (27%), C: n=4 (11%)). Infants with biliary atresia splenic malformation (BASM) or cat-eye syndrome (CES) contributed over half of the cases (21/37; 57%).Overall, 20 (54%) infants cleared jaundice (vs 50/77 (65%) controls; p=0.2), but with higher mortality compared with the non-cardiac controls (15/37 (40%) vs 3/77 (4%); HR 15.5 (95% CI 5.5 to 43.4); p<0.00001). Infants requiring cardiac intervention in the first year of life (n=15) were more likely to clear jaundice (6/7 vs 2/8; p=0.04) and had a trend towards higher survival (6/7 vs 3/8; p=0.1) when KPE followed cardiac surgery. Yet, the type of cardiac pathology did not impact clearance of jaundice or mortality. CONCLUSION We propose the term cardiac-associated biliary atresia (CABA) as a high-risk group. We believe that restorative cardiac surgery should precede KPE wherever possible to improve outcome.
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Affiliation(s)
- Bashar Aldeiri
- Department of Paediatric Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Vangelis Giamouris
- Department of Paediatric Hepatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Kuberan Pushparajah
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK.,School of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Owen Miller
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK.,Faculty of Life Sciences & Medicine, Kings College London, London, UK
| | - Alastair Baker
- Department of Paediatric Hepatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital NHS Foundation Trust, London, UK
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Abstract
Biliary atresia (BA) is a rare but severe fibroinflammatory disease of the extrahepatic and the intrahepatic bile ducts. Without prompt interventions, BA has fatal outcomes and is the most common indicator for pediatric liver transplantation (LTx). While the mainstay of treatment involves surgically correcting the extrahepatic biliary obstruction via Kasai hepato-portoenterostomy (KHPE), activation of a multitude of biological pathways and yet-to-be-determined etiology in BA continue to foster liver inflammation, cirrhosis and need for LTx. However, important caveats still exist in our understandings of the biliary pathophysiology, the rapidity of liver fibrosis and progression to liver failure, largely due to limited knowledge of the triggers of biliary injury and the inability to accurately model human BA. Although inconclusive, a large body of existing literature points to a potential viral infection in the early peri- or postnatal period as triggers of epithelial injury that perpetuates the downstream biliary disease. Further confounding this issue, are the lack of in-vivo and in-vitro models to efficiently recapitulate the cardinal features of BA, primarily liver fibrosis. To overcome these barriers in BA research, new directions in recent years have enabled (I) identification of additional triggers of biliary injury linked mostly to environmental toxins, (II) development of models to investigate liver fibrogenesis, and (III) translational research using patient-derived organoids. Here, we discuss recent advances that undoubtedly will stimulate future efforts investigating these new and exciting avenues towards mechanistic and drug discovery efforts and disease-preventive measures. The implications of these emerging scientific investigations and disease modeling in severe fibrosing cholangiopathies like BA are enormous and contribute substantially in our understandings of this rare but deadly disease. These findings are also expected to facilitate expeditious identification of translationally targetable pathways and bring us one step closer in treating an infant with BA, a population highly vulnerable to life-long liver related complications.
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Affiliation(s)
- Astha Malik
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Unmesha Thanekar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Reena Mourya
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Pranavkumar Shivakumar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
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So J, Ningappa M, Glessner J, Min J, Ashokkumar C, Ranganathan S, Higgs BW, Li D, Sun Q, Schmitt L, Biery AC, Dobrowolski S, Trautz C, Fuhrman L, Schwartz MC, Klena NT, Fusco J, Prasadan K, Adenuga M, Mohamed N, Yan Q, Chen W, Horne W, Dhawan A, Sharif K, Kelly D, Squires RH, Gittes GK, Hakonarson H, Morell V, Lo C, Subramaniam S, Shin D, Sindhi R. Biliary-Atresia-Associated Mannosidase-1-Alpha-2 Gene Regulates Biliary and Ciliary Morphogenesis and Laterality. Front Physiol 2020; 11:538701. [PMID: 33192543 PMCID: PMC7662016 DOI: 10.3389/fphys.2020.538701] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/23/2020] [Indexed: 01/10/2023] Open
Abstract
Background/Aims Infectious and genetic factors are invoked, respectively in isolated biliary atresia (BA), or syndromic BA, with major extrahepatic anomalies. However, isolated BA is also associated with minor extrahepatic gut and cardiovascular anomalies and multiple susceptibility genes, suggesting common origins. Methods We investigated novel susceptibility genes with genome-wide association, targeted sequencing and tissue staining in BA requiring liver transplantation, independent of BA subtype. Candidate gene effects on morphogenesis, developmental pathways, and ciliogenesis, which regulates left-right patterning were investigated with zebrafish knockdown and mouse knockout models, mouse airway cell cultures, and liver transcriptome analysis. Results Single nucleotide polymorphisms in Mannosidase-1-α-2 (MAN1A2) were significantly associated with BA and with other polymorphisms known to affect MAN1A2 expression but were not differentially enriched in either BA subtype. In zebrafish embryos, man1a2 knockdown caused poor biliary network formation, ciliary dysgenesis in Kupffer’s vesicle, cardiac and liver heterotaxy, and dysregulated egfra and other developmental genes. Suboptimal man1a2 knockdown synergized with suboptimal EGFR signaling or suboptimal knockdown of the EGFR pathway gene, adenosine-ribosylation-factor-6, which had minimal effects individually, to reproduce biliary defects but not heterotaxy. In cultured mouse airway epithelium, Man1a2 knockdown arrested ciliary development and motility. Man1a2–/– mice, which experience respiratory failure, also demonstrated portal and bile ductular inflammation. Human BA liver and Man1a2–/– liver exhibited reduced Man1a2 expression and dysregulated ciliary genes, known to cause multisystem human laterality defects. Conclusion BA requiring transplantation associates with sequence variants in MAN1A2. man1a2 regulates laterality, in addition to hepatobiliary morphogenesis, by regulating ciliogenesis in zebrafish and mice, providing a novel developmental basis for multisystem defects in BA.
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Affiliation(s)
- Juhoon So
- Department of Developmental Biology, McGowan Institute of Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Mylarappa Ningappa
- Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - Joseph Glessner
- Center for Applied Genomics of the Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jun Min
- Departments of Bioengineering, Cellular and Molecular Medicine, and Computer Science and Engineering, University of California San Diego, La Jolla, CA, United States
| | - Chethan Ashokkumar
- Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - Sarangarajan Ranganathan
- Division of Pediatric Pathology, Department of Pathology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Brandon W Higgs
- Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - Dong Li
- Center for Applied Genomics of the Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Qing Sun
- Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - Lori Schmitt
- Histology Core Laboratory, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Amy C Biery
- Division of Pediatric Pathology, Department of Pathology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Steven Dobrowolski
- Division of Pediatric Pathology, Department of Pathology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Christine Trautz
- Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - Leah Fuhrman
- Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | | | - Nikolai Thomas Klena
- Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Joseph Fusco
- Pediatric General and Thoracic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Krishna Prasadan
- Pediatric General and Thoracic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Morayooluwa Adenuga
- Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - Nada Mohamed
- Pediatric General and Thoracic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Qi Yan
- Departments of Human Genetics and Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Wei Chen
- Departments of Human Genetics and Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - William Horne
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Anil Dhawan
- Paediatric Liver, GI, and Nutrition, King's College Hospital, London, United Kingdom
| | - Khalid Sharif
- Children's Hospital of Birmingham, Birmingham, United Kingdom
| | - Deirdre Kelly
- Children's Hospital of Birmingham, Birmingham, United Kingdom
| | - Robert H Squires
- Pediatric Gastroenterology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - George K Gittes
- Pediatric General and Thoracic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Hakon Hakonarson
- Center for Applied Genomics of the Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Victor Morell
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Cecilia Lo
- Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Shankar Subramaniam
- Departments of Bioengineering, Cellular and Molecular Medicine, and Computer Science and Engineering, University of California San Diego, La Jolla, CA, United States
| | - Donghun Shin
- Department of Developmental Biology, McGowan Institute of Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Rakesh Sindhi
- Hillman Center for Pediatric Transplantation of the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
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del Castillo Velilla I, Martínez Jiménez M, Pascual Martín M, García Cabezas M. Lissencephaly, cerebellar hypoplasia, and extrahepatic biliary atresia: an unusual association. Neurología (English Edition) 2020. [DOI: 10.1016/j.nrleng.2020.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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35
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del Castillo Velilla I, Martínez Jiménez M, Pascual Martín M, García Cabezas M. Lisencefalia, hipoplasia cerebelar y atresia de vías biliares extrahepáticas: una asociación inusual. Neurologia 2020; 35:502-503. [DOI: 10.1016/j.nrl.2019.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/01/2019] [Accepted: 02/25/2019] [Indexed: 11/18/2022] Open
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Min J, Ningappa M, So J, Shin D, Sindhi R, Subramaniam S. Systems Analysis of Biliary Atresia Through Integration of High-Throughput Biological Data. Front Physiol 2020; 11:966. [PMID: 32848883 PMCID: PMC7426509 DOI: 10.3389/fphys.2020.00966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/15/2020] [Indexed: 01/07/2023] Open
Abstract
Biliary atresia (BA), blockage of the proper bile flow due to loss of extrahepatic bile ducts, is a rare, complex disease of the liver and the bile ducts with unknown etiology. Despite ongoing investigations to understand its complex pathogenesis, BA remains the most common cause of liver failure requiring liver transplantation in children. To elucidate underlying mechanisms, we analyzed the different types of high-throughput genomic and transcriptomic data collected from the blood and liver tissue samples of children suffering from BA. Through use of a novel integrative approach, we identified potential biomarkers and over-represented biological functions and pathways to derive a comprehensive network showing the dysfunctional mechanisms associated with BA. One of the pathways highlighted in the integrative network was hypoxia signaling. Perturbation with hypoxia inducible factor activator, dimethyloxalylglycine, induced the biliary defects of BA in a zebrafish model, serving as a validation for our studies. Our approach enables a systems-level understanding of human BA biology that is highlighted by the interaction between key biological functions such as fibrosis, inflammation, immunity, hypoxia, and development.
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Affiliation(s)
- Jun Min
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, United States
| | - Mylarappa Ningappa
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - Juhoon So
- Department of Developmental Biology, McGowan Institute of Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Donghun Shin
- Department of Developmental Biology, McGowan Institute of Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Rakesh Sindhi
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - Shankar Subramaniam
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, United States.,Departments of Cellular and Molecular Medicine and Computer Science and Engineering, University of California, San Diego, La Jolla, CA, United States
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Kelly C, Nayagam JS, Vogli S, Samyn M, Joshi D. Paediatric cholestatic liver disorders for the adult gastroenterologist: a practical guide. Frontline Gastroenterol 2020; 12:404-413. [PMID: 35401959 PMCID: PMC8989003 DOI: 10.1136/flgastro-2020-101554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/16/2020] [Accepted: 06/20/2020] [Indexed: 02/04/2023] Open
Abstract
With improvements in the outcomes for cholestatic liver diseases that present in childhood, increasing numbers of patients will require ongoing care as adults. The recent advances in management options coupled with the fact that each adult physician will have a limited number of patients with these conditions means there is a need for those in adult services to develop expertise in these conditions that were historically the domain of paediatrics. This review provides an overview of the most common paediatric cholestatic liver diseases and outlines the clinical manifestations and potential complications, and identifies key management issues unique to each condition for effective ongoing care of these patients.
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Affiliation(s)
- Claire Kelly
- Institute of Liver Studies, King's College Hospital, London, UK
| | | | - Stamatina Vogli
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Marianne Samyn
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
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Abo-Zeinah SS, Behairy B, Hussein MH, Khedr MA, El Azab DS, Adawy NM, Zakaria HM. Histopathological expression of Yes-associated protein in neonatal cholestasis. Clin Res Hepatol Gastroenterol 2020; 44:189-94. [PMID: 31279668 DOI: 10.1016/j.clinre.2019.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 06/06/2019] [Accepted: 06/07/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Biliary atresia (BA) is a common cause of persistent neonatal cholestasis and liver transplantation in the pediatric population. Yes-associated protein (YAP) has also been shown to be necessary for development of bile ducts and adaptive responses within the gastrointestinal tract. We aimed to evaluate the YAP expression in liver tissues of infants with neonatal cholestasis as well as its diagnostic potential in the differential diagnosis of BA. PATIENTS AND METHODS This prospective study included 100 infants with neonatal cholestasis. After full history taking, thorough clinical examination, routine investigations, and histopathological assessment, the patients were allocated as BA and non-BA; fifty patients in each group. Ten liver biopsies from 10 donors of liver transplant recipients served as controls. Diagnosis of BA was confirmed by operative cholangiography. Hepatic expression of YAP was assessed by immunohistochemical staining. RESULTS Presence of clay stool, elevated GGT and absence of gall bladder contractility were the main preliminary signs alarming for the possibility of BA. Bile ductular and interlobular biliary epithelium and hepatic lobule expression of YAP in patients with BA was significantly higher than that in Non-BA group (P<0.05). There was no or weak positive YAP expression in normal liver of transplant donors. Positive YAP immunohistochemical had a sensitivity of 80% and a specificity of 94% with accuracy 87% in discrimination between BA and non-BA group (P-value<0.0001). CONCLUSION Hepatic expression of YAP was significantly higher in BA than in non-BA group and could discriminate BA from other causes of cholestasis.
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Ortiz-Perez A, Donnelly B, Temple H, Tiao G, Bansal R, Mohanty SK. Innate Immunity and Pathogenesis of Biliary Atresia. Front Immunol 2020; 11:329. [PMID: 32161597 PMCID: PMC7052372 DOI: 10.3389/fimmu.2020.00329] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/10/2020] [Indexed: 12/12/2022] Open
Abstract
Biliary atresia (BA) is a devastating fibro-inflammatory disease characterized by the obstruction of extrahepatic and intrahepatic bile ducts in infants that can have fatal consequences, when not treated in a timely manner. It is the most common indication of pediatric liver transplantation worldwide and the development of new therapies, to alleviate the need of surgical intervention, has been hindered due to its complexity and lack of understanding of the disease pathogenesis. For that reason, significant efforts have been made toward the development of experimental models and strategies to understand the etiology and disease mechanisms and to identify novel therapeutic targets. The only characterized model of BA, using a Rhesus Rotavirus Type A infection of newborn BALB/c mice, has enabled the identification of key cellular and molecular targets involved in epithelial injury and duct obstruction. However, the establishment of an unleashed chronic inflammation followed by a progressive pathological wound healing process remains poorly understood. Like T cells, macrophages can adopt different functional programs [pro-inflammatory (M1) and resolutive (M2) macrophages] and influence the surrounding cytokine environment and the cell response to injury. In this review, we provide an overview of the immunopathogenesis of BA, discuss the implication of innate immunity in the disease pathogenesis and highlight their suitability as therapeutic targets.
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Affiliation(s)
- Ana Ortiz-Perez
- Department of Biomaterials Science and Technology, Technical Medical Centre, Faculty of Science and Technology, University of Twente, Enschede, Netherlands
| | - Bryan Donnelly
- Department of Pediatric and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Haley Temple
- Department of Pediatric and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Greg Tiao
- Department of Pediatric and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Ruchi Bansal
- Department of Biomaterials Science and Technology, Technical Medical Centre, Faculty of Science and Technology, University of Twente, Enschede, Netherlands
| | - Sujit Kumar Mohanty
- Department of Pediatric and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
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Rajagopalan R, Tsai EA, Grochowski CM, Kelly SM, Loomes KM, Spinner NB, Devoto M. Exome Sequencing in Individuals with Isolated Biliary Atresia. Sci Rep 2020; 10:2709. [PMID: 32066793 PMCID: PMC7026070 DOI: 10.1038/s41598-020-59379-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 01/22/2020] [Indexed: 12/13/2022] Open
Abstract
Biliary atresia (BA) is a severe pediatric liver disease resulting in necroinflammatory obliteration of the extrahepatic biliary tree. BA presents within the first few months of life as either an isolated finding or with additional syndromic features. The etiology of isolated BA is unknown, with evidence for infectious, environmental, and genetic risk factors described. However, to date, there are no definitive causal genes identified for isolated BA in humans, and the question of whether single gene defects play a major role remains open. We performed exome-sequencing in 101 North American patients of European descent with isolated BA (including 30 parent-child trios) and considered several experimental designs to identify potentially deleterious protein-altering variants that may be involved in the disease. In a case-only analysis, we did not identify genes with variants shared among more than two probands, and burden tests of rare variants using a case-case control design did not yield significant results. In the trio analysis of 30 simplex families (patient and parent trios), we identified 66 de novo variants in 66 genes including potentially deleterious variants in STIP1 and REV1. STIP1 is a co-chaperone for the heat-shock protein, HSP90, and has been shown to have diverse functions in yeast, flies and mammals, including stress-responses. REV1 is known to be a key player in DNA repair pathway and to interact with HSP90. In conclusion, our results do not support the hypothesis that a simple genetic model is responsible for the majority of cases of isolated BA. Our finding of de novo variants in genes linked to evolutionarily conserved stress responses (STIP1 and REV1) suggests that exploration of how genetic susceptibility and environmental exposure may interact to cause BA is warranted.
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Affiliation(s)
- Ramakrishnan Rajagopalan
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ellen A Tsai
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Genomics and Computational Biology Graduate Group, The University of Pennsylvania, Philadelphia, PA, USA.,Genetic Epidemiology Group, Department of Translational Biology, Biogen, Cambridge, MA, USA
| | - Christopher M Grochowski
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Susan M Kelly
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nancy B Spinner
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marcella Devoto
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Department of Translational and Precision Medicine, University La Sapienza, Rome, Italy.
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Mysore KR, Shneider BL, Harpavat S. Biliary Atresia as a Disease Starting In Utero: Implications for Treatment, Diagnosis, and Pathogenesis. J Pediatr Gastroenterol Nutr 2019; 69:396-403. [PMID: 31335837 DOI: 10.1097/MPG.0000000000002450] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biliary atresia (BA) is the most common reason for pediatric liver transplant. BA's varied presentation, natural history, and treatment with the Kasai portoenterostomy have been well described; however, when BA starts relative to birth has not been clearly defined. In this review, we discuss laboratory, imaging, and clinical data which suggest that most if not all forms of BA may start before birth. This early onset has implications in terms of delivering treatments earlier and identifying possible factors underlying BA's etiology.
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Bove KE, Thrasher AD, Anders R, Chung CT, Cummings OW, Finegold MJ, Finn L, Ranganathan S, Kim GE, Lovell M, Magid MS, Melin-Aldana H, Russo P, Shehata B, Wang L, White F, Chen Z, Spino C, Magee JC. Inflammation, Active Fibroplasia, and End-stage Fibrosis in 172 Biliary Atresia Remnants Correlate Poorly With Age at Kasai Portoenterostomy, Visceral Heterotaxy, and Outcome. Am J Surg Pathol 2018; 42:1625-35. [PMID: 30247160 DOI: 10.1097/PAS.0000000000001146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Published histologic studies of the hilar plate or entire biliary remnant at the time of Kasai portoenterostomy (KHPE) have not provided deep insight into the pathogenesis of biliary atresia, relation to age at surgery, prognosis or the basis for successful drainage. We report detailed histologic findings in 172 centrally reviewed biliary remnants with an average of 6 sections per subject. Active lesions were classified as either necroinflammatory (rare/clustered in a few subjects) or active concentric fibroplasia with or without inflammation (common). Inactive lesions showed bland replacement by collagen and fibrous cords with little or no inflammation. Heterogeneity was common within a given remnant; however, relatively homogenous histologic patterns, defined as 3 or more inactive or active levels in the hepatic ducts levels, characterized most remnants. Homogeneity did not correlate with age at KHPE, presence/absence of congenital anomalies at laparotomy indicative of heterotaxy and outcome. Remnants from youngest subjects were more likely than older subjects to be homogenously inactive suggesting significantly earlier onset in the youngest subset. Conversely remnants from the oldest subjects were often homogenously active suggesting later onset or slower progression. More data are needed in remnants from subjects <30 days old at KHPE and in those with visceral anomalies. Prevalence of partially preserved epithelium in active fibroplastic biliary atresia lesions at all ages suggests that epithelial regression or injury may not be a primary event or that reepithelialization is already underway at the time of KHPE. We hypothesize that outcome after KHPE results from competition between active fibroplasia and reepithelialization of retained, collapsed but not obliterated lumens. The driver of active fibroplasia is unknown.
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Berauer JP, Mezina AI, Okou DT, Sabo A, Muzny DM, Gibbs RA, Hegde MR, Chopra P, Cutler DJ, Perlmutter DH, Bull LN, Thompson RJ, Loomes KM, Spinner NB, Rajagopalan R, Guthery SL, Moore B, Yandell M, Harpavat S, Magee JC, Kamath BM, Molleston JP, Bezerra JA, Murray KF, Alonso EM, Rosenthal P, Squires RH, Wang KS, Finegold MJ, Russo P, Sherker AH, Sokol RJ, Karpen SJ. Identification of Polycystic Kidney Disease 1 Like 1 Gene Variants in Children With Biliary Atresia Splenic Malformation Syndrome. Hepatology 2019; 70:899-910. [PMID: 30664273 PMCID: PMC6642859 DOI: 10.1002/hep.30515] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 01/02/2019] [Indexed: 12/23/2022]
Abstract
Biliary atresia (BA) is the most common cause of end-stage liver disease in children and the primary indication for pediatric liver transplantation, yet underlying etiologies remain unknown. Approximately 10% of infants affected by BA exhibit various laterality defects (heterotaxy) including splenic abnormalities and complex cardiac malformations-a distinctive subgroup commonly referred to as the biliary atresia splenic malformation (BASM) syndrome. We hypothesized that genetic factors linking laterality features with the etiopathogenesis of BA in BASM patients could be identified through whole-exome sequencing (WES) of an affected cohort. DNA specimens from 67 BASM subjects, including 58 patient-parent trios, from the National Institute of Diabetes and Digestive and Kidney Diseases-supported Childhood Liver Disease Research Network (ChiLDReN) underwent WES. Candidate gene variants derived from a prespecified set of 2,016 genes associated with ciliary dysgenesis and/or dysfunction or cholestasis were prioritized according to pathogenicity, population frequency, and mode of inheritance. Five BASM subjects harbored rare and potentially deleterious biallelic variants in polycystic kidney disease 1 like 1 (PKD1L1), a gene associated with ciliary calcium signaling and embryonic laterality determination in fish, mice, and humans. Heterozygous PKD1L1 variants were found in 3 additional subjects. Immunohistochemical analysis of liver from the one BASM subject available revealed decreased PKD1L1 expression in bile duct epithelium when compared to normal livers and livers affected by other noncholestatic diseases. Conclusion: WES identified biallelic and heterozygous PKD1L1 variants of interest in 8 BASM subjects from the ChiLDReN data set; the dual roles for PKD1L1 in laterality determination and ciliary function suggest that PKD1L1 is a biologically plausible, cholangiocyte-expressed candidate gene for the BASM syndrome.
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Affiliation(s)
- John-Paul Berauer
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Emory University School of Medicine and Children’s Healthcare of Atlanta; Atlanta, GA, 30322, USA
| | - Anya I. Mezina
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Emory University School of Medicine and Children’s Healthcare of Atlanta; Atlanta, GA, 30322, USA
| | - David T. Okou
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Emory University School of Medicine and Children’s Healthcare of Atlanta; Atlanta, GA, 30322, USA
| | - Aniko Sabo
- Human Genome Sequencing Center; Baylor College of Medicine; Houston, TX, 77030, USA
| | - Donna M. Muzny
- Human Genome Sequencing Center; Baylor College of Medicine; Houston, TX, 77030, USA
| | - Richard A. Gibbs
- Human Genome Sequencing Center; Baylor College of Medicine; Houston, TX, 77030, USA
| | - Madhuri R. Hegde
- Department of Human Genetics; Emory University School of Medicine; Atlanta, GA, 30322, USA
| | - Pankaj Chopra
- Department of Human Genetics; Emory University School of Medicine; Atlanta, GA, 30322, USA
| | - David J. Cutler
- Department of Human Genetics; Emory University School of Medicine; Atlanta, GA, 30322, USA
| | - David H. Perlmutter
- Department of Pediatrics; Washington University School of Medicine; St. Louis, MO, 63110, USA
| | - Laura N. Bull
- Department of Medicine; Institute for Human Genetics, and Liver Center Laboratory, University of California San Francisco; San Francisco, CA, 94143, USA
| | | | - Kathleen M. Loomes
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Perelman School of Medicine at the University of Pennsylvania and Children’s Hospital of Philadelphia; Philadelphia, PA 19104, USA
| | - Nancy B. Spinner
- Department of Pathology and Laboratory Medicine; Division of Genomic Diagnostics; Children’s Hospital of Philadelphia; Philadelphia PA, 19104, USA
| | - Ramakrishnan Rajagopalan
- Department of Pathology and Laboratory Medicine; Division of Genomic Diagnostics; Children’s Hospital of Philadelphia; Philadelphia PA, 19104, USA
- Department of Biomedical and Health Informatics; Children’s Hospital of Philadelphia; Philadelphia PA, 19104, USA
| | - Stephen L. Guthery
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; University of Utah; and Intermountain Primary Children’s Hospital Salt Lake City, UT, 84112, USA
| | - Barry Moore
- Department of Human Genetics; University of Utah; Salt Lake City, UT, 84112, USA
| | - Mark Yandell
- Department of Human Genetics; University of Utah; Salt Lake City, UT, 84112, USA
| | - Sanjiv Harpavat
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Baylor College of Medicine; Houston, TX, 77030, USA
| | - John C. Magee
- University of Michigan Medical School; Ann Arbor, MI, 48103, USA
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology and Nutrition; Hospital for Sick Children and University of Toronto; Toronto, ON, M5G 1X8, Canada
| | - Jean P. Molleston
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Indiana University School of Medicine and Riley Hospital for Children; Indianapolis, IN, 46202, USA
| | - Jorge A. Bezerra
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Cincinnati Children’s Hospital Medical Center; Cincinnati, OH, 45229, USA
| | - Karen F. Murray
- Department of Pediatrics; Division of Gastroenterology and Hepatology; University of Washington School of Medicine and Seattle Children’s Hospital; Seattle, WA, 98105, USA
| | - Estella M. Alonso
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Ann and Robert H. Lurie Children’s Hospital of Chicago; Chicago, IL, 60611, USA
| | - Philip Rosenthal
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; University of California San Francisco; San Francisco, CA, 94143, USA
| | - Robert H. Squires
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Children’s Hospital of Pittsburgh of UPMC; Pittsburgh, PA, 15224, USA
| | - Kasper S. Wang
- Department of Surgery; Division of Pediatric Surgery; Children’s Hospital of Los Angeles; University of Southern California; Los Angeles, CO, 90027, USA
| | - Milton J. Finegold
- Department of Pediatrics; Department of Molecular and Cellular Biology; Baylor College of Medicine; Houston, TX, 77030, USA
| | - Pierre Russo
- Department of Pathology and Laboratory Medicine; Children’s Hospital of Philadelphia; Philadelphia PA, 19104, USA
| | - Averell H. Sherker
- Liver Diseases Research Branch; National Institute of Diabetes and Digestive and Kidney Diseases; National Institutes of Health; Bethesda, MD, 20892, USA
| | - Ronald J. Sokol
- Department of Pediatrics; Section of Gastroenterology, Hepatology and Nutrition; Children’s Hospital Colorado and University of Colorado School of Medicine; Aurora, CO, 80045, USA
| | - Saul J. Karpen
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Emory University School of Medicine and Children’s Healthcare of Atlanta; Atlanta, GA, 30322, USA
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Honigbaum S, Zhu Q, Layman A, Anders RA, Schwarz KB. Abundant Expression of Lysyl Oxidase-like 2 Protein in Intrahepatic Bile Ducts of Infants With Biliary Atresia. J Pediatr Gastroenterol Nutr 2019; 69:344-50. [PMID: 31436671 DOI: 10.1097/MPG.0000000000002414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Biliary atresia (BA) is characterized by rapidly progressive inflammation and fibrosis of the biliary tract, which usually progresses despite surgical intervention (Kasai hepatoportoenterostomy). Lysyl oxidase-like (LOXL2) is an extracellular matrix enzyme that catalyzes the cross-linking of fibrillar collagen and elastin and is thought to play a crucial role in tissue fibrosis; anti-LOXL2 drugs have been shown to be antifibrotic in animals. OBJECTIVE The aim of the study was to investigate the presence of LOXL2 in BA livers and hepatic and extrahepatic control tissues. METHODS Liver wedge biopsies from infants with BA (n = 20) were obtained at Kasai, and were compared with non-BA livers (n = 20). Liver fibrosis was scored using the Ishak scale, and immunohistochemistry was performed using a commercially available polyclonal anti-LOXL2 antibody. The expression of LOXL2 was scored for intensity and for distribution of bile duct staining by a pathologist blinded to the diagnosis. Staining of LOXL2 in pediatric control tissue, muscle (n = 5), heart (n = 5), and bone (n = 10) was performed. RESULTS Tissue from patients with BA abundantly expressed LOXL2 (intensity score 2.0 vs 1.4 [P ≤ 0.001]) for non-BA and distribution of bile duct-staining score of 3.0 versus 2.8 (P = 0.001) for non-BA. Fibrosis score of all BA samples was 4.2 versus 3.1 for non-BA. Nonhepatic pediatric tissue displayed minimal to no LOXL2 staining. CONCLUSIONS There is significant overexpression of LOXL2 in BA hepatic tissue with minimal expression in extrahepatic tissue. The over expression noted in human hepatic tissue at Kasai suggests the rationale for further investigation of anti-LOXL2 therapeutics in BA.
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Abstract
RATIONALE Liver transplanted patients have excellent survival rates, but infectious complications are a major cause of morbidity and mortality. Diagnosis and treatment of tuberculosis (TB) in liver recipients are very challenging. Specific recommendations for anti-TB treatment in liver transplanted patients are lacking. PATIENT CONCERNS AND DIAGNOSIS A 22-year-old male liver transplanted patient because of biliary atresia showed unexpected acute hemoptysis while he was on immunosuppressive therapy with tacrolimus and mycophenolate mofetil. Computed tomography (CT) identified a pulmonary arteriovenous malformation (PAVM) successfully treated with endovascular embolization. A post-embolization thoracic CT revealed pulmonary cavitation and miliary pattern suggesting pulmonary TB causing PAVM. TB diagnosis was confirmed by microbiological assays and genetic amplification techniques. INTERVENTION Anti-TB 4-drug regimen was started. Following the beginning of treatment, liver enzymes increased. In order to clarify if liver cytolysis was due to hepatotoxicity or hepatic rejection linked to the reduction of immunosuppression or a worsening of pre-existing graft hepatitis, a liver biopsy was performed. A mild graft rejection was found so that tacrolimus doses were increased despite the risk of tubercular dissemination. OUTCOME The patient completed anti-TB therapy in 8 months with resolution of TB disease and stable liver disease. LESSONS TB management in liver transplanted patients is challenging and needs to be individualized especially if chronic graft hepatitis is present.
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Affiliation(s)
- Fabiola Di Dato
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II
| | - Francesco Nunziata
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II
| | - Margherita Rosa
- Pediatric Emergency Department, Azienda Ospedaliera di Rilievo Nazionale Santobono-Pausilipon, Naples, Italy
| | - Raffaele Iorio
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II
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Abstract
Navigating the complexities of interpreting a liver biopsy performed on a neonate with conjugated/direct hyperbilirubinemia can be an arduous task given these biopsies are infrequently encountered. The list of entities is long and yet there are only a few histologic patterns of liver injury. The first step for the pathologist is to determine the histologic pattern, which will guide further inquiry into the useful clinical information to have while evaluating the biopsy. Ultimately, the goal is to identify those conditions that will benefit from early intervention. We begin with a review of biliary development to help understand what findings may be physiologic versus pathologic, particularly in premature infants. Then we review eight cases that cover the three most common histologic patterns of injury in patients with neonatal cholestasis: biliary obstructive, neonatal hepatitis, and paucity of intrahepatic bile ducts. The entities that serve as prototypes for these histologic patterns are covered, including biliary atresia, idiopathic neonatal hepatitis, and Alagille syndrome, along with rarer entities that have histologic overlap. The cases with accompanying tables and algorithms are intended to help place the histologic findings in the context of the overall clinical work-up, including genetic testing.
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Affiliation(s)
- Soo-Jin Cho
- Department of Pathology, University of California San Francisco, San Francisco, CA United States
| | - Grace E Kim
- Department of Pathology, University of California San Francisco, San Francisco, CA United States.
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Aspelund G, Mahdi EM, Rothstein DH, Wakeman DS. Transitional care for patients with surgical pediatric hepatobiliary disease: Choledochal cysts and biliary atresia. J Gastroenterol Hepatol 2019; 34:966-974. [PMID: 30552863 DOI: 10.1111/jgh.14575] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 11/13/2018] [Accepted: 12/09/2018] [Indexed: 12/14/2022]
Abstract
Choledochal cysts (CDCs) and biliary atresia (BA) are rare pediatric hepatobiliary anomalies that require surgical intervention due to increased risk of malignancy and liver failure, respectively. The underlying disease and operative procedures place patients at risk for long-term complications, which may continue to affect them into adulthood. Lack of a transitional care model in the health-care system potentiates the challenges they will face following aging out of their pediatric providers' care. We sought to elucidate the long-term complications and challenges patients with CDCs and BA face, review the current literature regarding transitioning care, and propose guidelines aiding adult providers in continued care and surveillance of these patients. A literature review was performed to assess short-term and long-term complications after surgery and the current standards for transitioning care in patients with a history of CDCs and BA. While transitional programs exist for patients with other gastrointestinal diseases, there are few that focus on CDCs or BA. Generally, authors encourage medical record transmission from pediatric to adult providers, ensuring accuracy of information and compliance with treatment plans. Patients with CDCs are at risk for developing biliary malignancies, cholangitis, and anastomotic strictures after resection. Patients with BA develop progressive liver failure, necessitating transplantation. There are no consensus guidelines regarding timing of follow up for these patients. Based on the best available evidence, we propose a schema for long-term surveillance.
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Affiliation(s)
- Gudrun Aspelund
- Department of Pediatric Surgery, Maria Fareri Children's Hospital, Valhalla, New York, USA
| | - Elaa M Mahdi
- Department of Surgery, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
| | - David H Rothstein
- Department of Pediatric Surgery, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Derek S Wakeman
- Department of Surgery, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
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Abstract
BACKGROUND Biliary atresia (BA) is the most common cause of obstructive jaundice in infants. Although the Kasai procedure has greatly improved the prognosis, most patients still need liver transplantation (LT) for long-term survival. The pathogenesis of BA has not been fully clarified, and liver fibrosis in BA is far beyond biliary obstructive cirrhosis. DATA SOURCES Literature reviews were underwent through PubMed. Persistent inflammation, immune response, biliary epithelial-mesenchymal transition, matrix deposition, decompensated angiogenesis, and unique biliary structure development all contribute to the fibrosis process. Observed evidences in such fields have been collected and form the backbone of this review. RESULTS Interactions of the multiple pathways accelerate this process. CONCLUSIONS Understanding the mechanisms of the liver fibrosis in BA may pave the way to improved survival after the Kasai procedure.
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Affiliation(s)
- Wen-Jun Shen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Gong Chen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Min Wang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Shan Zheng
- Department of Pediatric Surgery, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China.
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Taylor SA, Malladi P, Pan X, Wechsler JB, Hulse KE, Perlman H, Whitington PF. Oligoclonal immunoglobulin repertoire in biliary remnants of biliary atresia. Sci Rep 2019; 9:4508. [PMID: 30872727 PMCID: PMC6418100 DOI: 10.1038/s41598-019-41148-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 03/01/2019] [Indexed: 12/13/2022] Open
Abstract
Biliary atresia (BA) is a neonatal cholestatic liver disease that is the leading cause of pediatric liver transplantation, however, the mechanism of disease remains unknown. There are two major forms of BA: isolated BA (iBA) comprises the majority of cases and is thought to result from an aberrant immune response to an environmental trigger, whereas syndromic BA (BASM) has associated malformations and is thought to arise from a congenital insult. To determine whether B cells in BA biliary remnants are antigen driven, we examined the immunoglobulin (Ig) repertoire of diseased tissue from each BA group. Deep sequencing of the Ig chain DNA was performed on iBA and BASM biliary remnants and lymph nodes obtained from the Childhood Liver Disease Research Network (ChiLDReN) repository. Statistical analysis of the Ig repertoire provided measures of Ig clonality and the Ig phenotype. Our data demonstrate that B cells infiltrate diseased iBA and BASM biliary remnant tissue. The Ig repertoires of iBA and BASM disease groups were oligoclonal supporting a role for an antigen-driven immune response in both sub-types. These findings shift the current understanding of BA and suggest a role for antigen stimulation in early iBA and BASM disease pathogenesis.
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Affiliation(s)
- Sarah A Taylor
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States. .,Stanley Manne Children's Research Institute, Chicago, Illinois, United States.
| | - Padmini Malladi
- Stanley Manne Children's Research Institute, Chicago, Illinois, United States
| | - Xiaomin Pan
- Stanley Manne Children's Research Institute, Chicago, Illinois, United States
| | - Joshua B Wechsler
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
| | - Kathryn E Hulse
- Department of Medicine, Northwestern University, Chicago, Illinois, United States
| | - Harris Perlman
- Department of Medicine, Northwestern University, Chicago, Illinois, United States
| | - Peter F Whitington
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States.,Stanley Manne Children's Research Institute, Chicago, Illinois, United States
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Abstract
PURPOSE OF REVIEW Biliary atresia is a poorly understood deadly disease. Genetic predisposition factors are suspected albeit not firmly established. This review summarizes recent evidence of genetic alterations in biliary atresia. RECENT FINDINGS Whole-genome association studies in biliary atresia patients identified four distinct predisposition loci with four different genes potentially involved in the disease occurrence. Variations in these genes were searched for, but none were found in patients with biliary atresia suggesting complex mechanisms. SUMMARY Despite decades since its description and decades of intensive researches, cause of biliary atresia disease remains enigmatic. The inheritance of biliary atresia is not Mendelian. Genetic predisposition factor is one of the explored fields to explain biliary atresia pathogenicity. Biliary atresia has been associated with several inborn syndromes, chromosome anomalies, and gene polymorphisms in specific populations. Four predisposition loci encompassing genes relevant to the disease have been identified, but no pathogenic variations were found in biliary atresia patients. Few reported cases of isolated biliary atresia manifestation in the context of known genetic diseases suggest coincidental findings. Alternatives to classic genetic alterations are proposed to explain genetic predisposition in biliary atresia including noncoding and epigenetic factors. Biliary atresia is most likely related to complex traits making its genetic exploration challenging.
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