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Sankararaman S, Freeman AJ. Early detection of hepatobiliary involvement in cystic fibrosis: Biomarkers, radiologic methods, and genetic influences. Pediatr Pulmonol 2024; 59 Suppl 1:S107-S114. [PMID: 39105338 DOI: 10.1002/ppul.26892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 01/10/2024] [Accepted: 01/21/2024] [Indexed: 08/07/2024]
Abstract
Cystic fibrosis-related hepatobiliary involvement (CFHBI) is a term used to describe a spectrum of hepatobiliary involvement ranging from a transient elevation of transaminase levels to advanced cystic fibrosis-associated liver disease (aCFLD). While CFHBI is common among people with cystic fibrosis (PwCF), aCFLD is rare impacting only approximately 5%-10% of the CF population. After respiratory/cardiorespiratory issues and transplant-related complications, aCFLD is now the 4th leading cause of mortality among PwCF. Additionally, aCFLD is an independent predictor of all-cause mortality and is associated with significant morbidity. Despite this recognition, our ability to predict those patients at greatest risk for aCFLD, identify early aCFLD, and monitor the incremental progression of CFHBI is lacking. Here, we review the strengths and weaknesses of the common biomarkers and imaging modalities used in the evaluation and monitoring of CFHBI, as well as the current understanding of genetic modifiers related to aCFLD.
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Affiliation(s)
- Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
- Case Western Reserve University SOM, Cleveland, Ohio, USA
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Nationwide Children's Hospital, Columbus, Ohio, USA
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2
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Burgel PR, Southern KW, Addy C, Battezzati A, Berry C, Bouchara JP, Brokaar E, Brown W, Azevedo P, Durieu I, Ekkelenkamp M, Finlayson F, Forton J, Gardecki J, Hodkova P, Hong G, Lowdon J, Madge S, Martin C, McKone E, Munck A, Ooi CY, Perrem L, Piper A, Prayle A, Ratjen F, Rosenfeld M, Sanders DB, Schwarz C, Taccetti G, Wainwright C, West NE, Wilschanski M, Bevan A, Castellani C, Drevinek P, Gartner S, Gramegna A, Lammertyn E, Landau EEC, Plant BJ, Smyth AR, van Koningsbruggen-Rietschel S, Middleton PG. Standards for the care of people with cystic fibrosis (CF); recognising and addressing CF health issues. J Cyst Fibros 2024; 23:187-202. [PMID: 38233247 DOI: 10.1016/j.jcf.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 01/19/2024]
Abstract
This is the third in a series of four papers updating the European Cystic Fibrosis Society (ECFS) standards for the care of people with CF. This paper focuses on recognising and addressing CF health issues. The guidance was produced with wide stakeholder engagement, including people from the CF community, using an evidence-based framework. Authors contributed sections, and summary statements which were reviewed by a Delphi consultation. Monitoring and treating airway infection, inflammation and pulmonary exacerbations remains important, despite the widespread availability of CFTR modulators and their accompanying health improvements. Extrapulmonary CF-specific health issues persist, such as diabetes, liver disease, bone disease, stones and other renal issues, and intestinal obstruction. These health issues require multidisciplinary care with input from the relevant specialists. Cancer is more common in people with CF compared to the general population, and requires regular screening. The CF life journey requires mental and emotional adaptation to psychosocial and physical challenges, with support from the CF team and the CF psychologist. This is particularly important when life gets challenging, with disease progression requiring increased treatments, breathing support and potentially transplantation. Planning for end of life remains a necessary aspect of care and should be discussed openly, honestly, with sensitivity and compassion for the person with CF and their family. CF teams should proactively recognise and address CF-specific health issues, and support mental and emotional wellbeing while accompanying people with CF and their families on their life journey.
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Affiliation(s)
- Pierre-Régis Burgel
- Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Institut Cochin, Inserm U1016, Université Paris-Cité, Paris, France
| | - Kevin W Southern
- Department of Women's and Children's Health, Institute in the Park, Alder Hey Children's Hospital, University of Liverpool, Eaton Road, Liverpool L12 2AP, UK.
| | - Charlotte Addy
- All Wales Adult Cystic Fibrosis Centre, University Hospital Llandough, Cardiff and Vale University Health Board, Cardiff, UK
| | - Alberto Battezzati
- Clinical Nutrition Unit, Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, and ICANS-DIS, Department of Food Environmental and Nutritional Sciences, University of Milan, Milan, Italy
| | - Claire Berry
- Department of Nutrition and Dietetics, Alder Hey Children's NHS Trust, Liverpool, UK
| | - Jean-Philippe Bouchara
- University of Brest, Fungal Respiratory Infections Research Unit, SFR ICAT, University of Angers, Angers, France
| | - Edwin Brokaar
- Department of Pharmacy, Haga Teaching Hospital, The Hague, the Netherlands
| | - Whitney Brown
- Cystic Fibrosis Foundation, Inova Fairfax Hospital, Bethesda, Maryland, USA, Falls Church, VA, USA
| | - Pilar Azevedo
- Cystic Fibrosis Reference Centre-Centro, Hospitalar Universitário Lisboa Norte, Portugal
| | - Isabelle Durieu
- Cystic Fibrosis Reference Center (Constitutif), Service de médecine interne et de pathologie vasculaire, Hospices Civils de Lyon, Hôpital Lyon Sud, RESearch on HealthcAre PErformance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69373 Lyon Cedex 08, France; ERN-Lung Cystic Fibrosis Network, Frankfurt, Germany
| | - Miquel Ekkelenkamp
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Felicity Finlayson
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Australia
| | | | - Johanna Gardecki
- CF Centre at Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Pavla Hodkova
- CF Center at University Hospital Motol, Prague, Czech Republic
| | - Gina Hong
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jacqueline Lowdon
- Clinical Specialist Paediatric Cystic Fibrosis Dietitian, Leeds Children's Hospital, UK
| | - Su Madge
- Royal Brompton Hospital, Part of Guys and StThomas's Hospital, London, UK
| | - Clémence Martin
- Institut Cochin, Inserm U1016, Université Paris-Cité and National Reference Center for Cystic Fibrosis, Hôpital Cochin AP-HP, ERN-Lung CF Network, Paris 75014, France
| | - Edward McKone
- St.Vincent's University Hospital and University College Dublin School of Medicine, Dublin, Ireland
| | - Anne Munck
- Hospital Necker Enfants-Malades, AP-HP, CF Centre, Université Paris Descartes, Paris, France
| | - Chee Y Ooi
- School of Clinical Medicine, Discipline of Paediatrics and Child Health, Faculty of Medicine & Health, Department of Gastroenterology, Sydney Children's Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Lucy Perrem
- Department of Respiratory Medicine, Children's Health Ireland, Dublin, Ireland
| | - Amanda Piper
- Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Andrew Prayle
- Child Health, Lifespan and Population Health & Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics and Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Margaret Rosenfeld
- Department of Pediatrics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA, USA
| | - Don B Sanders
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carsten Schwarz
- Division Cystic Fibrosis, CF Center, Clinic Westbrandenburg, HMU-Health and Medical University, Potsdam, Germany
| | - Giovanni Taccetti
- Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Centre, Italy
| | | | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Wilschanski
- Pediatric Gastroenterology Unit, CF Center, Hadassah Medical Center, Jerusalem, Israel
| | - Amanda Bevan
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Carlo Castellani
- IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, Genova 16147, Italy
| | - Pavel Drevinek
- Department of Medical Microbiology, Second Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Silvia Gartner
- Cystic Fibrosis Unit and Pediatric Pulmonology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Respiratory Unit and Adult Cystic Fibrosis Center, Università degli Studi di Milano, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Elise Lammertyn
- Cystic Fibrosis Europe, Brussels, Belgium and the Belgian CF Association, Brussels, Belgium
| | - Eddie Edwina C Landau
- The Graub CF Center, Pulmonary Institute, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Barry J Plant
- Cork Centre for Cystic Fibrosis (3CF), Cork University Hospital, University College Cork, Ireland
| | - Alan R Smyth
- School of Medicine, Dentistry and Biomedical Sciences, Belfast and NIHR Nottingham Biomedical Research Centre, Queens University Belfast, Nottingham, UK
| | | | - Peter G Middleton
- Westmead Clinical School, Department Respiratory & Sleep Medicine, Westmead Hospital, University of Sydney and CITRICA, Westmead, Australia
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El-Faramawy A, Nasr SZ, Emam MMSA, Fahmy HMH. Clinical and genetic risk factors for cystic fibrosis-related liver disease in Egyptian CF children: A single-center experience. Pediatr Pulmonol 2024; 59:465-471. [PMID: 38038166 DOI: 10.1002/ppul.26775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 11/14/2023] [Accepted: 11/17/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) is an autosomal recessive disease. It affects multiple organ systems, including the liver, leading to CF-related liver disease (CFLD). It was noted that CFLD in Egyptian children with CF is more common than in non-Egyptian people with CF (pwCF). This study aimed to determine the incidence of CFLD and the potential risk factors for developing CFLD in Egyptian children. The correlation between CFLD and the various genotypes prevalent in Egyptian CF children will be discussed. In addition, comparison of CFLD in Egyptian and non-Egyptian CF patients will be presented. METHODS This cross-sectional study included 50 pwCF from Ain Sham University's Pediatric Pulmonology Clinic in Children's Hospital, Cairo, Egypt. The sweat chloride test and genetic studies were done at the time of diagnosis. Additionally, all subjects underwent detailed history taking, laboratory investigations, clinical assessment, and pelvic abdominal ultrasound for evaluation of hepatic involvement. RESULTS One-third of the Egyptian children with CF were found to have liver disease. The following independent risk factors for developing CFLD were identified as: male sex, severe genetic mutation (class I and II), long duration of CF disease, early onset of the CF, pancreatic insufficiency, as well as history of meconium ileus. In addition, diabetes mellitus and severe lung disease were proven to significantly increase the risk of developing CFLD. CONCLUSION CFLD is common in Egyptian pwCF. CFLD's risk factors are similar to other reported research from other countries in the region.
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Affiliation(s)
- Amel El-Faramawy
- Pediatrics Department, Hepatology Unit, Children's Hospital, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Samya Z Nasr
- Department of Pediatrics, Division of Pediatric Pulmonology, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Mohamed M S Al Emam
- Pediatrics Department, Hepatology Unit, Children's Hospital, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Heba M H Fahmy
- Pediatrics Department, Pulmonology Unit, Children's Hospital, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Assessment of Liver Fibrosis with the Use of Elastography in Paediatric Patients with Diagnosed Cystic Fibrosis. DISEASE MARKERS 2022; 2022:4798136. [PMID: 35345868 PMCID: PMC8957431 DOI: 10.1155/2022/4798136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 03/02/2022] [Indexed: 11/18/2022]
Abstract
Background Complications of cystic fibrosis-associated liver disease (CFLD) are a leading nonpulmonary cause of death. Noninvasive tests enabling early detection of liver changes, especially in children are sought. The aim of the study was to assess the scale of liver fibrosis with the use of elastography in paediatric patients with diagnosed cystic fibrosis (CF) and its comparison with other tests (APRI and Fibrotest). Methods We examined 41 children, in the age range 2-21 years, with diagnosed CF. The analysis a included clinical picture, laboratory parameters of liver damage, and cholestasis. Aspartate aminotransferase-to-platelet ratio index (APRI) and Fibrotest were done in all patients. Liver stiffness measurements were acquired using shear-wave elastography (SWE). Results CFLD was diagnosed in 16/41 patients (39%). Abnormal elastography was observed in 19/41 patients (46.3%), and in 5/41 (12.2%), the changes were advanced (F4). Abnormal elastography was observed in 12/16 (75%) of the patients with CFLD, and in 7/25 (28%), there were no lesions observed in the liver in the course of cystic fibrosis. In all patients with F4, we observed abnormal results of the APRI and Fibrotest. In most patients with small changes in elastography, we found normal results of the APRI and Fibrotest. Conclusion Elastography seems to be a noninvasive examination useful in everyday clinical work in detecting early liver changes and monitoring of progression in paediatric patients with diagnosed cystic fibrosis, ahead of changes in laboratory tests. The cost-effectiveness of this test, the possibility of its repetition, and its availability are additional benefits.
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Scott J, Jones AM, Piper Hanley K, Athwal VS. Review article: epidemiology, pathogenesis and management of liver disease in adults with cystic fibrosis. Aliment Pharmacol Ther 2022; 55:389-400. [PMID: 35048397 DOI: 10.1111/apt.16749] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/18/2021] [Accepted: 12/13/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cystic fibrosis-related liver disease (CFLD) is the leading cause of death in cystic fibrosis (CF), after pulmonary disease. To improve identification and management of this condition requires an understanding of the underlying disease mechanism. AIMS This review summarises the current understanding of CFLD epidemiology, pathology, diagnosis and management. METHODS Relevant reports on cystic fibrosis liver disease were identified using a literature search and summarised. RESULTS CFLD is a heterogeneous condition with several different co-existent pathologies, including environmental and genetic factors. Incidence of clinically significant CFLD continues at a linear rate into early adulthood and has been described in up to 25% of CF patients. Diagnosis strategies lack precision and patient risk stratification needs to look beyond Childs-Pugh scoring. Efficacious therapies are lacking and, at present, newer modulator therapies lack data in CFLD and carry an increased risk of hepatotoxicity. Outcomes of liver transplant are comparable to non-CF transplant indications. CONCLUSIONS The incidence of CFLD increases with age and hence is increasingly important to adult patients with CF. Effective therapies are lacking. For progress to be made a better understanding of pathogenesis and disease detection are required.
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Affiliation(s)
- Jennifer Scott
- Division of Gastroenterology and Hepatology, Manchester University NHS Foundation Trust, Manchester, UK
- Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Andrew M Jones
- Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
- Manchester Adult Cystic Fibrosis Centre, Manchester University NHS Foundation Trust UK, Manchester, UK
| | - Karen Piper Hanley
- Division of Gastroenterology and Hepatology, Manchester University NHS Foundation Trust, Manchester, UK
- Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Varinder S Athwal
- Division of Gastroenterology and Hepatology, Manchester University NHS Foundation Trust, Manchester, UK
- Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
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Cystic fibrosis-related liver disease: Clinical presentations, diagnostic and monitoring approaches in the era of CFTR modulator therapies. J Hepatol 2022; 76:420-434. [PMID: 34678405 DOI: 10.1016/j.jhep.2021.09.042] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/09/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022]
Abstract
Cystic fibrosis (CF) is the most common autosomal recessive disease in the Caucasian population. Cystic fibrosis-related liver disease (CFLD) is defined as the pathogenesis related to the underlying CFTR defect in biliary epithelial cells. CFLD needs to be distinguished from other liver manifestations that may not have any pathological significance. The clinical/histological presentation and severity of CFLD vary. The main histological presentation of CFLD is focal biliary fibrosis, which is usually asymptomatic. Portal hypertension develops in a minority of cases (about 10%) and may require specific management including liver transplantation for end-stage liver disease. Portal hypertension is usually the result of the progression of focal biliary fibrosis to multilobular cirrhosis during childhood. Nevertheless, non-cirrhotic portal hypertension as a result of porto-sinusoidal vascular disease is now identified increasingly more frequently, mainly in young adults. To evaluate the effect of new CFTR modulator therapies on the liver, the spectrum of hepatobiliary involvement must first be precisely classified. This paper discusses the phenotypic features of CFLD, its underlying physiopathology and relevant diagnostic and follow-up approaches, with a special focus on imaging.
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Non-invasive diagnosis and follow-up of rare genetic liver diseases. Clin Res Hepatol Gastroenterol 2022; 46:101768. [PMID: 34332127 DOI: 10.1016/j.clinre.2021.101768] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 07/23/2021] [Indexed: 02/04/2023]
Abstract
Rare genetic liver diseases can result in multi-systemic damage, which may compromise the patient's prognosis. Wilson's disease and alpha-1 antitrypsin deficiency must be investigated in any patient with unexplained liver disease. Cystic fibrosis screening of new-borns is now implemented in most high-prevalence countries. The diagnosis of these diseases can be strongly suggested with specific non-invasive tests. Molecular analysis gene for these diseases is long and tedious but is recommended to confirm the diagnosis and help for the family screening. Liver biopsy is not systematic and is discussed when it helps diagnosis. Currently, for these three diseases, non-invasive fibrosis markers could identify patients with risk of cirrhosis and complications. Rare genetic liver diseases can result in multi-systemic damage, which may compromise the patient's prognosis. Wilson's disease, must be investigated in any patient with unexplained liver disease and/or unexplained neurological or neuropsychiatric disorders. The diagnosis is based on a combination of clinical, biological features, including copper balance. The exchangeable copper/total copper ratio is a new sensible and specific biological marker, useful for the diagnosis of the disease. Timely diagnosis and treatment will prevent serious complications from the disease. Neurological evaluation and familial screening are essential in patients with Wilson's disease.
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Marinero Martínez-Lázaro A, Girón Moreno RM, Casals Seoane F, Cano-Valderrama Ó, García-Buey L. Cystic fibrosis with liver involvement in adults has a benign course. Results from a tertiary referral centre cohort. REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS 2022; 114. [DOI: 10.17235/reed.2022.9289/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Advanced but not mild liver disease is a predictor of decreased survival in children with cystic fibrosis, with far greater impact in females: A 27-year real-life cohort study. J Cyst Fibros 2021; 21:230-235. [PMID: 34949555 DOI: 10.1016/j.jcf.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/19/2021] [Accepted: 11/23/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Improved survival of children with CF has increased our need to understand the relevance of cystic fibrosis-associated liver disease (CFLD). We assessed the impact of liver disease and disease severity on the survival of children with cystic fibrosis. METHODS A real life, single center cohort study with 27 years follow up was conducted. Mild CFLD was diagnosed as children with abnormal serum liver function tests and abnormal ultrasound. Advanced CFLD was established by detection of cirrhosis or portal hypertension. A directed acyclic graph, Kaplan-Meier (KM) and Cox regression analysis were used to model survival. RESULTS 290 patients were enrolled, 48 (16.5%) had mild CFLD and 55 (19%) had advanced CFLD. Ten children with advanced CFLD and 1 with mild CFLD died. Based on the KM analysis, the mean (SE) overall survival age of all CF children was 29.1 years (0.50). The mean (SE) survival among females with advanced CFLD was 24.7 years (1.58) compared to 30.4 years (0.66) for females without advanced CFLD (p = 0.0027). Advanced CFLD was a predictor of decreased survival when adjusted for sex and diabetes (HR 2.54, 95%CI 1.05-6.15, p = 0.039). Mild CFLD was not associated with decreased survival. The effect of advanced CFLD on survival was mainly borne by females (HR = 6.37, 95%CI 1.62-25.06 vs. males, HR = 1.00, 95%CI 0.25-4.01). CONCLUSION Advanced but not mild CFLD was associated with an increased risk of death when adjusted for sex and diabetes, and resulted in premature death in females with cystic fibrosis by approximately 6 years.
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Magnetic resonance imaging of cystic fibrosis: Multi-organ imaging in the age of CFTR modulator therapies. J Cyst Fibros 2021; 21:e148-e157. [PMID: 34879996 DOI: 10.1016/j.jcf.2021.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 12/18/2022]
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Flemming G, Baumann U, Richter N, Vondran F, Tümmler B, Dittrich AM, Müller C, Vogel M, Pfister ED. Survival Benefits Following Liver Transplantation: A Matched-pair Analysis in Pediatric Patients With Cystic Fibrosis. J Pediatr Gastroenterol Nutr 2021; 73:385-390. [PMID: 34091543 DOI: 10.1097/mpg.0000000000003194] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Cystic fibrosis-related liver disease (CFLD) with consecutive cirrhosis is the third most common cause of death in CF patients. The aim of this study was to identify the potential long-term benefits of liver transplantation (LTx) in a match-control comparison. METHODS Retrospective single-center data analysis of all pediatric LTx for CFLD between 1998 and 2014. A control group was selected from the local CF patient registry. Data were collected from case report forms and included clinical and laboratory data, lung function tests, the indication for LTx, and details of surgical procedures. RESULTS At our institution, 23 patients with severe CFLD median age 13.8 years (range 8.7-17.4; 16 boys) underwent LTx between 1998 and 2014. In all patients, normalization of hepatic CF manifestations were achieved after LTx. But obviously there was no significant positive influence on nutritional status. Signs of posttransplant liver steatosis were documented by ultrasound in 17 patients. Liver biopsies after LTx were performed in 19 patients, in 42% (n = 8) of these biopsies a fatty degeneration was observed. Five patients died after LTx, none because of primary hepatic dysfunction (1 because of posttransplant proliferative disorder, 4 because of infection). Analysis of matched control pairs revealed that liver function, anthropometry, pulmonary function, and life expectancy of CFLD patients with LTx are comparable with matched CF peers without CFLD. CONCLUSIONS Isolated LTx normalizes the hepatic manifestation of CF disease. LTx enables children and adolescents with severe CFLD to have a comparable prognosis in terms of growth, life expectancy, and lung function as CF patients without advanced liver involvement. Our data clarifies the long-term perspectives of affected patients.
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Affiliation(s)
- Gunter Flemming
- Pediatric Gastrolenterology and Hepatology, Hannover Medical School, Hannover
- Hospital for Children and Adolescents, University of Leipzig
| | - Ulrich Baumann
- Pediatric Gastrolenterology and Hepatology, Hannover Medical School, Hannover
| | | | | | - Burkhard Tümmler
- Pediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - Anna-Maria Dittrich
- Pediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - Carsten Müller
- Pediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - Mandy Vogel
- Hospital for Children and Adolescents, University of Leipzig
| | - Eva-Doreen Pfister
- Pediatric Gastrolenterology and Hepatology, Hannover Medical School, Hannover
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Sasame A, Stokes D, Bourke B, Connolly L, Fitzpatrick E, Rowland M. The impact of liver disease on mortality in cystic fibrosis-A systematic review. J Cyst Fibros 2021; 21:202-211. [PMID: 34380590 DOI: 10.1016/j.jcf.2021.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/12/2021] [Accepted: 07/24/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND There is conflicting evidence on the impact of liver disease (CFLD) on life expectancy in CF. Therefore the aim of this systematic review was to evaluate the impact of liver disease (CFLD) on mortality in CF. METHODS The protocol was published at (https://hrbopenresearch.org/articles/3-44/v3) using PRISPMA-P guidelines and registered in Prospero 2020 (CRD42020182885). Three databases were searched for publications (1938-2020) where the outcome was all-cause mortality (defined as death and transplantation) or CF-specific mortality in participants with CFLD. Studies with and without a comparator group were included. Studies were divided into 2 groups based on the definition of CFLD: Group 1 used 2 categories of liver disease (i) liver disease with portal hypertension (PH) (ii) non-specific abnormalities which did not meet the criteria for PH, Group 2 studies only included participants with PH. RESULTS All 14 eligible studies were observational, with a moderate-high risk of bias, Six of the 14 studies directly compared mortality between those with CFLD and those with no liver disease, and 5/6 demonstrated that those with CFLD had at least 3 time the risk of death compared to those with no liver disease. Pulmonary complications were the primary cause of death. CONCLUSION This SR demonstrates that liver disease shortens life expectancy in CF, and that pulmonary complications are the primary cause of death in those with CFLD. There has been no improvement in survival for persons with CFLD despite significant improvements in life expectancy for persons with CF who have no evidence of liver disease.
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Affiliation(s)
- Ao Sasame
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland
| | - Diarmuid Stokes
- UCD Library, University College Dublin, Belfield, Dublin 4, Ireland
| | - Billy Bourke
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland; Children's Health Ireland at Crumlin, Crumlin, Dublin 12, Ireland; King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Lucy Connolly
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland
| | - Emer Fitzpatrick
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland; Children's Health Ireland at Crumlin, Crumlin, Dublin 12, Ireland; King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Marion Rowland
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland.
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Hyzny EJ, Chan EG, Morrell M, Harano T, Sanchez PG. A review of liver dysfunction in the lung transplant patient. Clin Transplant 2021; 35:e14344. [PMID: 33960530 DOI: 10.1111/ctr.14344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/09/2021] [Accepted: 04/26/2021] [Indexed: 12/11/2022]
Abstract
Liver dysfunction is an increasingly common finding in patients evaluated for lung transplantation. New or worsening dysfunction in the perioperative period, defined by presence of clinical ascites/encephalopathy, high model for end-stage liver disease (MELD) score, and/or independent diagnostic criteria, is associated with high short- and long-term mortality. Therefore, a thorough liver function assessment is necessary prior to listing for lung transplant. Unfortunately, identification and intraoperative monitoring remain the only options for prevention of disease progression with isolated lung transplantation. Combined lung and liver transplantation may provide an option for definitive long-term management in selecting patients with known liver disease at high risk for postoperative progression. However, experience with the combined operation is extremely limited and indications for combined lung and liver transplant remain unclear. Herein, we present a comprehensive literature review of patients with liver dysfunction undergoing lung transplantation with and without concurrent liver transplant in an effort to illuminate the risks, benefits, and clinical judgement surrounding decision to pursue combined lung-liver transplantation (CLLT). We also argue description of liver function is currently a weakness of the current lung allocation scoring system. Additional algorithms incorporating liver function may aid in risk stratification and decision to pursue combined transplantation.
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Affiliation(s)
- Eric J Hyzny
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew Morrell
- Pulmonary, Allergy, and Critical Care Medicine Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Takashi Harano
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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14
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Gao E, Hercun J, Heller T, Vilarinho S. Undiagnosed liver diseases. Transl Gastroenterol Hepatol 2021; 6:28. [PMID: 33824932 DOI: 10.21037/tgh.2020.04.04] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/19/2020] [Indexed: 02/06/2023] Open
Abstract
The landscape of chronic liver disease has drastically changed over the past 20 years, largely due to advances in antiviral therapy and the rise of metabolic syndrome and associated non-alcoholic fatty liver disease (NAFLD). Despite advances in the diagnosis and treatment of a variety of liver diseases, the burden of chronic liver disease is increasing worldwide. The first step to addressing any disease is accurate diagnosis. Here, we discuss liver diseases that remain undiagnosed, either because they are difficult to diagnose or due to hepatic manifestations of an unrecognized systemic disease. Additionally, their underlying etiology may remain unknown or they represent previously uncharacterized and therefore novel liver diseases. Our goal is to provide a framework for approaching undiagnosed liver diseases which elude standard hepatic diagnostic work-up and whose patterns of disease are often overlooked.
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Affiliation(s)
- Emily Gao
- Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Julian Hercun
- Translational Hepatology Section, National Institute of Diabetes & Digestive & Kidney Diseases, National Institute of Health, Bethesda, MD, USA
| | - Theo Heller
- Translational Hepatology Section, National Institute of Diabetes & Digestive & Kidney Diseases, National Institute of Health, Bethesda, MD, USA
| | - Sílvia Vilarinho
- Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA.,Department of Pathology, Yale School of Medicine, New Haven, CT, USA
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15
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Signorelli P, Pivari F, Barcella M, Merelli I, Zulueta A, Dei Cas M, Rosso L, Ghidoni R, Caretti A, Paroni R, Mingione A. Myriocin modulates the altered lipid metabolism and storage in cystic fibrosis. Cell Signal 2021; 81:109928. [PMID: 33482299 DOI: 10.1016/j.cellsig.2021.109928] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/13/2021] [Accepted: 01/13/2021] [Indexed: 12/12/2022]
Abstract
Cystic fibrosis (CF) is a hereditary disease mostly related to ΔF508 CFTR mutation causing a proteinopathy that is characterized by multiple organ dysfunction, primarily lungs chronic inflammation, and infection. Defective autophagy and accumulation of the inflammatory lipid ceramide have been proposed as therapeutic targets. Accumulation of lipids and cholesterol was reported in the airways of CF patients, together with altered triglycerides and cholesterol levels in plasma, thus suggesting a disease-related dyslipidemia. Myriocin, an inhibitor of sphingolipids synthesis, significantly reduces inflammation and activates TFEB-induced response to stress, enhancing fatty acids oxidation and promoting autophagy. Myriocin ameliorates the response against microbial infection in CF models and patients' monocytes. Here we show that CF broncho-epithelial cells exhibit an altered distribution of intracellular lipids. We demonstrated that lipid accumulation is supported by an enhanced synthesis of fatty acids containing molecules and that Myriocin is able to reduce such accumulation. Moreover, Myriocin modulated the transcriptional profile of CF cells in order to restore autophagy, activate an anti-oxidative response, stimulate lipid metabolism and reduce lipid peroxidation. Moreover, lipid storage may be altered in CF cells, since we observed a reduced expression of lipid droplets related proteins named perilipin 3 and 5 and seipin. To note, Myriocin up-regulates the expression of genes that are involved in lipid droplets biosynthesis and maturation. We suggest that targeting sphingolipids de novo synthesis may counteract lipids accumulation by modulating CF altered transcriptional profile, thus restoring autophagy and lipid metabolism homeostasis.
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Affiliation(s)
- Paola Signorelli
- Biochemistry and Molecular Biology Laboratory, Department of Health Science, University of Milan, Milan, Italy; "Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, University of Milan, Milan, Italy
| | - Francesca Pivari
- Biochemistry and Molecular Biology Laboratory, Department of Health Science, University of Milan, Milan, Italy
| | - Matteo Barcella
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Ivan Merelli
- Institute for Biomedical Technologies, National Research Council of Italy, Milan, Italy
| | - Aida Zulueta
- Biochemistry and Molecular Biology Laboratory, Department of Health Science, University of Milan, Milan, Italy
| | - Michele Dei Cas
- Laboratory of Clinical Biochemistry and Mass Spectrometry, Department of Health Sciences, University of Milan, Milan, Italy
| | - Lorenzo Rosso
- Thoracic surgery and transplantation Unit, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Health Sciences Department, University of Milan, Milan, Italy
| | - Riccardo Ghidoni
- Biochemistry and Molecular Biology Laboratory, Department of Health Science, University of Milan, Milan, Italy; "Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, University of Milan, Milan, Italy
| | - Anna Caretti
- Biochemistry and Molecular Biology Laboratory, Department of Health Science, University of Milan, Milan, Italy
| | - Rita Paroni
- Laboratory of Clinical Biochemistry and Mass Spectrometry, Department of Health Sciences, University of Milan, Milan, Italy
| | - Alessandra Mingione
- Biochemistry and Molecular Biology Laboratory, Department of Health Science, University of Milan, Milan, Italy; "Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, University of Milan, Milan, Italy.
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16
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Sasame A, Connolly L, Fitzpatrick E, Stokes D, Bourke B, Rowland M. The impact of liver disease on mortality in cystic fibrosis - a systematic review protocol. HRB Open Res 2021; 3:44. [PMID: 33305166 PMCID: PMC7713883 DOI: 10.12688/hrbopenres.13065.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2020] [Indexed: 12/11/2022] Open
Abstract
Background Cystic fibrosis (CF) is a multiorgan disease affecting the lungs pancreas and gastrointestinal tract. Pulmonary complications are the most common manifestation of the disease. Recent advances in the treatment of pulmonary complications have resulted in substantial improvement in life expectancy. Less than 10% of persons with CF (PWCF) develop liver disease (CFLD). There is conflicting evidence about impact of liver disease on mortality in CF, with evidence suggesting that CFLD contributes to increased mortality in CF, while other studies suggest that the impact on mortality is limited. Understanding the contribution of liver disease to mortality in CF is essential if further improvements in life expectancy are to be achieved. Objective: To document the impact of liver disease on life expectancy for PWCF. Methods: This systematic review will be conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P 2015). PubMed, Medline and Embase will be searched for English language publications (1949-2020). Studies reporting the outcome for CFLD will be included where the definition of CFLD is outlined clearly in a CF population. Studies with and without a comparator will be evaluated. Clinical trials of ursodeoxycholic acid will be excluded as well as organ transplantation outcome studies. We will examine all-cause and specific causes of mortality.We will include transplantation in our estimates of all-cause mortality. The Axis Risk of Bias Tool for Observational Studies will be used to evaluate the quality of studies. We will provide a narrative synthesis of our findings using tabular formats to highlight any impact of liver disease on mortality in CF. Conclusion: It is anticipated that this review will bring clarity to the question of whether CFLD shortens life expectancy in PWCF and stimulate new approaches to the management of CFLD.
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Affiliation(s)
- Ao Sasame
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Lucy Connolly
- School of Medicine, University College Dublin, Dublin, Ireland
| | | | - Diarmuid Stokes
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Billy Bourke
- School of Medicine, University College Dublin, Dublin, Ireland.,Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Marion Rowland
- School of Medicine, University College Dublin, Dublin, Ireland
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17
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A bird eye view on cystic fibrosis: An underestimated multifaceted chronic disorder. Life Sci 2020; 268:118959. [PMID: 33383045 DOI: 10.1016/j.lfs.2020.118959] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 01/19/2023]
Abstract
Cystic fibrosis (CF) is an autosomal recessive disease which involves the mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. CF involves in the inflammatory processes and is considered as a multisystem disorder that is not confined to lungs, but it also affects other vital organs that leads to numerous co-morbidities. The respiratory disorder in the CF results in mortality and morbidity which is characterized by series of serious events involving mucus hypersecretion, microbial infections, airways obstruction, inflammation, destruction of epithelium, tissue remodeling and terminal lung diseases. Mucins are the high molecular weight glycoproteins important for the viscoelastic properties of the mucus, play a significant role in the disease mechanisms. Determining the functional association between the CFTR and mucins might help to identify the putative target for specific therapeutic approach. In fact, furin enzyme which helps in the entry of novel COVID-19 virus into the cell, is upregulated in CF and this can also serve as a potential target for CF treatment. Moreover, the use of nano-formulations for CF treatment is an area of research being widely studied as they have also demonstrated promising outcomes. The in-depth knowledge of non-coding RNAs like miRNAs and lncRNAs and their functional association with CFTR gene expression and mutation can provide a different range of opportunity to identify the promising therapeutic approaches for CF.
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18
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Sasame A, Connolly L, Fitzpatrick E, Stokes D, Bourke B, Rowland M. The impact of liver disease on mortality in cystic fibrosis - a systematic review protocol. HRB Open Res 2020; 3:44. [PMID: 33305166 DOI: 10.12688/hrbopenres.13065.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2020] [Indexed: 02/06/2023] Open
Abstract
Background Cystic fibrosis (CF) is a multiorgan disease affecting the lungs pancreas and gastrointestinal tract. Pulmonary complications are the most common manifestation of the disease. Recent advances in the treatment of pulmonary complications have resulted in substantial improvement in life expectancy. Less than 10% of persons with CF (PWCF) develop liver disease (CFLD). There is conflicting evidence about impact of liver disease on mortality in CF, with evidence suggesting that CFLD contributes to increased mortality in CF, while other studies suggest that the impact on mortality is limited. Understanding the contribution of liver disease to mortality in CF is essential if further improvements in life expectancy are to be achieved. Objective: To document the impact of liver disease on life expectancy for PWCF. Methods: This systematic review will be conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P 2015). PubMed, Medline and Embase will be searched for English language publications (1949-2020). Studies reporting the outcome for CFLD will be included where the definition of CFLD is outlined clearly in a CF population. Studies with and without a comparator will be evaluated. Clinical trials of ursodeoxycholic acid will be excluded as well as organ transplantation outcome studies. We will examine all-cause and specific causes of mortality.We will include transplantation in our estimates of all-cause mortality. The Axis Risk of Bias Tool for Observational Studies will be used to evaluate the quality of studies. We will provide a narrative synthesis of our findings using tabular formats to highlight any impact of liver disease on mortality in CF. Conclusion: It is anticipated that this review will bring clarity to the question of whether CFLD shortens life expectancy in PWCF and stimulate new approaches to the management of CFLD.
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Affiliation(s)
- Ao Sasame
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Lucy Connolly
- School of Medicine, University College Dublin, Dublin, Ireland
| | | | - Diarmuid Stokes
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Billy Bourke
- School of Medicine, University College Dublin, Dublin, Ireland.,Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Marion Rowland
- School of Medicine, University College Dublin, Dublin, Ireland
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19
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Staufer K. Current Treatment Options for Cystic Fibrosis-Related Liver Disease. Int J Mol Sci 2020; 21:E8586. [PMID: 33202578 PMCID: PMC7696864 DOI: 10.3390/ijms21228586] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/08/2020] [Accepted: 11/11/2020] [Indexed: 02/07/2023] Open
Abstract
Cystic Fibrosis-related liver disease (CFLD) has become a leading cause of morbidity and mortality in patients with Cystic Fibrosis (CF), and affects children and adults. The understanding of the pathogenesis of CFLD is key in order to develop efficacious treatments. However, it remains complex, and has not been clarified to the last. The search for a drug might be additionally complicated due to the diverse clinical picture and lack of a unified definition of CFLD. Although ursodeoxycholic acid has been used for decades, its efficacy in CFLD is controversial, and the potential of Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) modulators and targeted gene therapy in CFLD needs to be defined in the near future. This review focuses on the current knowledge on treatment strategies for CFLD based on pathomechanistic viewpoints.
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Affiliation(s)
- Katharina Staufer
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, 3010 Bern, Switzerland; ; Tel.: +41-31-63-2-74-88
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20
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Sasame A, Connolly L, Fitzpatrick E, Stokes D, Bourke B, Rowland M. The impact of liver disease on mortality in cystic fibrosis - a systematic review protocol. HRB Open Res 2020; 3:44. [DOI: 10.12688/hrbopenres.13065.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2020] [Indexed: 11/20/2022] Open
Abstract
Background Cystic fibrosis (CF) is a multiorgan disease affecting the lungs pancreas and gastrointestinal tract. Pulmonary complications are the most common manifestation of the disease. Recent advances in the treatment of pulmonary complications have resulted in substantial improvement in life expectancy. Less than 10% of persons with CF (PWCF) develop liver disease (CFLD). There is conflicting evidence about impact of liver disease on mortality in CF, with evidence suggesting that CFLD contributes to increased mortality in CF, while other studies suggest that the impact on mortality is limited. Understanding the contribution of liver disease to mortality in CF is essential if further improvements in life expectancy are to be achieved. Objective: To document the impact of liver disease on life expectancy for PWCF. Methods: This systematic review will be conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P 2015). PubMed, Medline and Embase will be searched for English language publications (1949-2020). Studies reporting the outcome for CFLD will be included where the definition of CFLD is outlined clearly in a CF population. Studies with and without a comparator will be evaluated. Clinical trials of ursodeoxycholic acid will be excluded as well as organ transplantation outcome studies. We will examine all-cause and specific causes of mortality.We will include transplantation in our estimates of all-cause mortality. The Axis Risk of Bias tool for observational will be used to evaluate the quality of studies. We will provide a narrative synthesis of our findings using tabular formats to highlight any impact of liver disease on mortality in CF. Conclusion: It is anticipated that this review will bring clarity to the question of whether CFLD shortens life expectancy in PWCF and stimulate new approaches to the management of CFLD.
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21
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Abstract
As improvements in nutritional and pulmonary care increase the life expectancy of cystic fibrosis (CF) patients, CF-associated liver disease (CFLD) is emerging as a cause of mortality. CFLD is the third leading cause of death in CF patients. We performed a search on PubMed and Google Scholar for published articles on CFLD. We reviewed the articles found in the literature search and gave priority to recent publications and studies with larger sample sizes. The prevalence of CFLD in the CF population is around 23% with a range of 2-62% and that prevalence increases linearly with age from 3.7% at age 5 to 32.2% at age 30. CFLD can present clinically in various ways such as hepatomegaly, variceal hemorrhage, persistent elevation of liver enzymes, and micro-gallbladder. Due to the focal nature of fibrosis in majority cases of CFLD, liver biopsies are sparsely performed for diagnosis or the marker of liver fibrosis. Although the mechanism of CFLD development is still unknown, many potential factors are reported. Some mutations of CFTR such as having a homozygous F508del mutation has been reported to increase the risk of developing CFLD and its severity. Having the SERPINA1 Z allele, a history of pancreatic insufficiency, a history meconium ileus, CF-related diabetes, or being male increases the risk of developing CFLD. Environmental factors do not appear to have significant effect on modulating CFLD development. Ursodeoxycholic acid is commonly used to treat or prevent CFLD, but the efficacy of this treatment is questionable.
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Affiliation(s)
- Paul Wasuwanich
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN, USA
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Nutrition, and Hepatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA -
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22
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Assessment of Selected Parameters of Liver Fibrosis and Inflammation in Patients with Diagnosed Cystic Fibrosis. Mediators Inflamm 2020; 2020:5696185. [PMID: 32308556 PMCID: PMC7132586 DOI: 10.1155/2020/5696185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/23/2020] [Accepted: 03/14/2020] [Indexed: 11/17/2022] Open
Abstract
Changes in the liver and bile ducts observed in patients diagnosed with cystic fibrosis result from inflammatory processes as well as fibrosis, remodeling, apoptosis, and cholestasis. As a consequence, portal hypertension, cirrhosis, and hepatic failure may develop. So far, the complexity of these processes has not been elucidated. Study Objectives. The aim of the study was to evaluate the selected parameters of hepatitis and fibrosis (Fibrotest, Actitest, and APRI) in patients diagnosed with cystic fibrosis. Material and Methods. The study included 79 patients with cystic fibrosis, aged 1 to 20 years (mean age 9.8 years), 49 girls (62%) and 30 boys (38%). The analysis involved the following: age, sex, clinical manifestations, laboratory tests evaluating pancreas function, parameters of liver damage, and cholestasis. Fibrotest, Actitest, and APRI were performed in all subjects. Results. Elevated parameters of hepatic cell damage (hypertransaminasemia) were found in 31/79 (39.2%) patients, while abnormal cholestasis parameters in 21/79 (26.6%). The abnormal results of Fibrotest were reported in 15% of patients (12/79), while of Actitest in 10% (8/79). In contrast, elevated APRI values were found in only 7.6% (6/79) of subjects. There was a statistically significant correlation between APRI and age (higher values were observed in younger children) and between Fibrotest and Actitest and pancreatic insufficiency (higher values were found in subjects without this abnormality). Moreover, Fibrotest values were significantly higher in girls. There was no correlation between Fibrotest, Actitest, and APRI values and the type of mutation. Conclusion. It appears that Fibrotest may be used as an early marker of liver fibrosis in patients with cystic fibrosis. Increased APRI values were only found in subjects with advanced hepatic lesions, most often in the form of portal hypertension.
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23
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Hepatobiliary Involvement in Cystic Fibrosis. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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24
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Hercun J, Alvarez F, Vincent C, Bilodeau M. Cystic fibrosis liver disease: A condition in need of structured transition and continuity of care. CANADIAN LIVER JOURNAL 2019; 2:71-83. [PMID: 35990223 PMCID: PMC9202747 DOI: 10.3138/canlivj-2018-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 09/10/2018] [Indexed: 08/05/2023]
Abstract
Liver disease affects one-third of patients with cystic fibrosis (CF) and it is one of the major causes of morbidity and mortality in these patients. Historically considered a disease of childhood, its impact is now seen more often in adulthood. The heterogeneous pattern of CF liver disease and its rapid progression to cirrhosis remain a diagnostic challenge and new questions pertaining to the nature of liver involvement have recently been raised. Non-invasive measures to stratify the severity of liver involvement are increasingly used to predict clinical outcomes. A single treatment, ursodeoxycholic acid, has been used to slow progression of liver disease while recent advances in the field of CF treatments are promising. Management of portal hypertension remains challenging but outcomes after liver transplantation are encouraging. While many questions remain unanswered, a growing number of CF patients reach adulthood and will require care for CF liver disease.
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Affiliation(s)
- Julian Hercun
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
| | - Fernando Alvarez
- Gastroenterology, Hepatology and Nutrition Division, CHU Sainte-Justine, Montréal, Québec
| | - Catherine Vincent
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
| | - Marc Bilodeau
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
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25
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Fabris L, Fiorotto R, Spirli C, Cadamuro M, Mariotti V, Perugorria MJ, Banales JM, Strazzabosco M. Pathobiology of inherited biliary diseases: a roadmap to understand acquired liver diseases. Nat Rev Gastroenterol Hepatol 2019; 16:497-511. [PMID: 31165788 PMCID: PMC6661007 DOI: 10.1038/s41575-019-0156-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Bile duct epithelial cells, also known as cholangiocytes, regulate the composition of bile and its flow. Acquired, congenital and genetic dysfunctions in these cells give rise to a set of diverse and complex diseases, often of unknown aetiology, called cholangiopathies. New knowledge has been steadily acquired about genetic and congenital cholangiopathies, and this has led to a better understanding of the mechanisms of acquired cholangiopathies. This Review focuses on findings from studies on Alagille syndrome, polycystic liver diseases, fibropolycystic liver diseases (Caroli disease and congenital hepatic fibrosis) and cystic fibrosis-related liver disease. In particular, knowledge on the role of Notch signalling in biliary repair and tubulogenesis has been advanced by work on Alagille syndrome, and investigations in polycystic liver diseases have highlighted the role of primary cilia in biliary pathophysiology and the concept of biliary angiogenic signalling and its role in cyst growth and biliary repair. In fibropolycystic liver disease, research has shown that loss of fibrocystin generates a signalling cascade that increases β-catenin signalling, activates the NOD-, LRR- and pyrin domain-containing 3 inflammasome, and promotes production of IL-1β and other chemokines that attract macrophages and orchestrate the process of pericystic and portal fibrosis, which are the main mechanisms of progression in cholangiopathies. In cystic fibrosis-related liver disease, lack of cystic fibrosis transmembrane conductance regulator increases the sensitivity of epithelial Toll-like receptor 4 that sustains the secretion of nuclear factor-κB-dependent cytokines and peribiliary inflammation in response to gut-derived products, providing a model for primary sclerosing cholangitis. These signalling mechanisms may be targeted therapeutically and they offer a possibility for the development of novel treatments for acquired cholangiopathies.
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Affiliation(s)
- Luca Fabris
- Liver Center, Department of Medicine, Yale University, New Haven, CT, USA
- Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Romina Fiorotto
- Liver Center, Department of Medicine, Yale University, New Haven, CT, USA
| | - Carlo Spirli
- Liver Center, Department of Medicine, Yale University, New Haven, CT, USA
| | | | - Valeria Mariotti
- Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Maria J Perugorria
- Department of Liver and Gastrointestinal Diseases, Biodonostia Health Research Institute, Donostia University Hospital, University of the Basque Country (UPV/EHU), San Sebastian, Spain
- National Institute for the Study of Liver and Gastrointestinal Diseases (CIBERehd, Instituto de Salud Carlos III), Madrid, Spain
- IKERBASQUE, Basque Foundation for Science, Bilbao, Spain
| | - Jesus M Banales
- Department of Liver and Gastrointestinal Diseases, Biodonostia Health Research Institute, Donostia University Hospital, University of the Basque Country (UPV/EHU), San Sebastian, Spain
- National Institute for the Study of Liver and Gastrointestinal Diseases (CIBERehd, Instituto de Salud Carlos III), Madrid, Spain
- IKERBASQUE, Basque Foundation for Science, Bilbao, Spain
| | - Mario Strazzabosco
- Liver Center, Department of Medicine, Yale University, New Haven, CT, USA.
- Department of Molecular Medicine, University of Padova, Padova, Italy.
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26
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Fiorotto R, Strazzabosco M. Pathophysiology of Cystic Fibrosis Liver Disease: A Channelopathy Leading to Alterations in Innate Immunity and in Microbiota. Cell Mol Gastroenterol Hepatol 2019; 8:197-207. [PMID: 31075352 PMCID: PMC6664222 DOI: 10.1016/j.jcmgh.2019.04.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 04/24/2019] [Accepted: 04/24/2019] [Indexed: 12/12/2022]
Abstract
Cystic fibrosis (CF) is a monogenic disease caused by mutation of Cftr. CF-associated liver disease (CFLD) is a common nonpulmonary cause of mortality in CF and accounts for approximately 2.5%-5% of overall CF mortality. The peak of the disease is in the pediatric population, but a second wave of liver disease in CF adults has been reported in the past decade in association with an increase in the life expectancy of these patients. New drugs are available to correct the basic defect in CF but their efficacy in CFLD is not known. The cystic fibrosis transmembrane conductance regulator, expressed in the apical membrane of cholangiocytes, is a major determinant for bile secretion and CFLD classically has been considered a channelopathy. However, the recent findings of the cystic fibrosis transmembrane conductance regulator as a regulator of epithelial innate immunity and the possible influence of the intestinal disease with an altered microbiota on the liver complication have opened new mechanistic insights on the pathogenesis of CFLD. This review provides an overview of the current understanding of the pathophysiology of the disease and discusses a potential target for intervention.
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Affiliation(s)
- Romina Fiorotto
- Section of Digestive Diseases, Yale Liver Center, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
| | - Mario Strazzabosco
- Section of Digestive Diseases, Yale Liver Center, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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27
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Cirrhosis associated with decreased survival and a 10-year lower median age at death of cystic fibrosis patients in the Netherlands. J Cyst Fibros 2019; 18:385-389. [DOI: 10.1016/j.jcf.2018.11.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/10/2018] [Accepted: 11/14/2018] [Indexed: 11/18/2022]
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The emerging burden of liver disease in cystic fibrosis patients: A UK nationwide study. PLoS One 2019; 14:e0212779. [PMID: 30947265 PMCID: PMC6448894 DOI: 10.1371/journal.pone.0212779] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 02/08/2019] [Indexed: 02/08/2023] Open
Abstract
Objective Cystic fibrosis associated liver disease (CFLD) is the third largest cause of mortality in CF. Our aim was to define the burden of CFLD in the UK using national registry data and identify risk factors for progressive disease. Methods A longitudinal population-based cohort study was conducted. Cases were defined as all patients with CFLD identified from the UK CF Registry, 2008–2013 (n = 3417). Denominator data were derived from the entire UK CF Registry. The burden of CFLD was characterised. Regression analysis was undertaken to identify risk factors for cirrhosis and progression. Results Prevalence of CFLD increased from 203.4 to 228.3 per 1000 patients during 2008–2013. Mortality in CF patients with CFLD was more than double those without; cirrhotic patients had higher all-cause mortality (HR 1.54, 95% CI 1.09 to 2.18, p = 0.015). Median recorded age of cirrhosis diagnosis was 19 (range 5–53) years. Male sex, Pseudomonas airway infection and CF related diabetes were independent risk factors for cirrhosis. Ursodeoxycholic acid use was associated with prolonged survival in patients without cirrhosis. Conclusions This study highlights an important changing disease burden of CFLD. The prevalence is slowly increasing and, importantly, the disease is not just being diagnosed in childhood. Although the role of ursodeoxycholic acid remains controversial, this study identified a positive association with survival.
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Boëlle P, Debray D, Guillot L, Clement A, Corvol H, on behalf of the French CF Modifier Gene Study Investigators. Cystic Fibrosis Liver Disease: Outcomes and Risk Factors in a Large Cohort of French Patients. Hepatology 2019; 69:1648-1656. [PMID: 30058245 PMCID: PMC6519059 DOI: 10.1002/hep.30148] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 06/09/2018] [Indexed: 12/12/2022]
Abstract
Cystic fibrosis (CF)-related liver disease (CFLD) is a common symptom in patients with CF. However, its prevalence, risk factors, and evolution are unclear. We analyzed a large database of patients with CF to investigate the incidence of CFLD, its related risk factors, and the use and effect of ursodeoxycholic acid (UDCA) treatment. We retrospectively analyzed 3,328 CF patients with pancreatic insufficiency born after 1985 and recruited into the French CF Modifier Gene Study since 2004. We determined liver status, age at CFLD and severe CFLD onset, sex, CFTR genotype, history of meconium ileus, treatment with UDCA, and respiratory and nutritional status. The incidence of CFLD increased by approximately 1% every year, reaching 32.2% by age 25. The incidence of severe CFLD increased only after the age of 5, reaching 10% by age 30. Risk factors for CFLD and severe CFLD were male sex, CFTR F508del homozygosity, and history of meconium ileus. Increasingly precocious initiation of UDCA treatment did not change the incidence of severe CFLD. Finally, patients with severe CFLD had worse lung function and nutritional status than other CF patients. Conclusion: CFLD occurs not only during childhood but also later in the lifetime of patients with CF; male sex, CFTR F508del homozygosity, and history of meconium ileus are independent risk factors for CFLD development; earlier use of UDCA over the last 20 years has not changed the incidence of severe CFLD, leading to questions about the use of this treatment in young children given its possible adverse effects.
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Affiliation(s)
- Pierre‐Yves Boëlle
- Sorbonne Université, INSERM, Institut Pierre Louis d’épidémiologie et de Santé Publique, IPLESP, APHP, Hôpital Saint‐AntoineParisFrance
| | - Dominique Debray
- Pediatric Hepatology UnitAP‐HP, Hôpital Necker Enfants MaladesParisFrance,Sorbonne Université, INSERM, Centre de Recherche Saint‐Antoine, CRSAParisFrance
| | - Loic Guillot
- Sorbonne Université, INSERM, Centre de Recherche Saint‐Antoine, CRSAParisFrance
| | - Annick Clement
- Pediatric Pulmonology DepartmentAP‐HP, Hôpital TrousseauParisFrance,Physiopathologie des Maladies Genetiques d’Expression PediatriqueSorbonne Université, INSERMParisFrance
| | - Harriet Corvol
- Sorbonne Université, INSERM, Centre de Recherche Saint‐Antoine, CRSAParisFrance,Pediatric Pulmonology DepartmentAP‐HP, Hôpital TrousseauParisFrance
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Han JL, Beal EW, Mumtaz K, Washburn K, Black SM. Combined liver-lung transplantation: Indications, outcomes, current experience and ethical Issues. Transplant Rev (Orlando) 2019; 33:99-106. [DOI: 10.1016/j.trre.2018.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/14/2018] [Accepted: 11/15/2018] [Indexed: 01/29/2023]
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Abstract
PURPOSE OF REVIEW Cystic fibrosis (CF; OMIM 219700) is caused by variations in the cystic fibrosis transmembrane conductance regulator gene. CF-related liver disease (CFLD) affects approximately one-third of patients with CF, but the severity of CFLD is highly variable. This review provides the latest knowledge in the pathophysiology and CF genetic modifier research in CFLD. RECENT FINDINGS So far, the only modifier gene validated in CFLD is SERPINA1 (α-1-antitrypsin) Z allele. Recent studies support the view that cholangiopathy arising in CF is the result of an ill-adapted innate immune response to endotoxins coming from the intestine and triggering a pro-inflammatory response. SUMMARY The pathophysiology of liver disease remains uncertain and so far, no therapy has proven effective to prevent the progression of CFLD. A better understanding of the pathophysiology and the effect of environmental and non-cystic fibrosis transmembrane conductance regulator genetic influences in the context of CFLD development would help improve management and develop new drug therapies.
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Poetter-Lang S, Staufer K, Baltzer P, Tamandl D, Muin D, Bastati N, Halilbasic E, Hodge JC, Trauner M, Kazemi-Shirazi L, Ba-Ssalamah A. The Efficacy of MRI in the diagnostic workup of cystic fibrosis-associated liver disease: A clinical observational cohort study. Eur Radiol 2019; 29:1048-1058. [PMID: 30054796 PMCID: PMC6302923 DOI: 10.1007/s00330-018-5650-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 06/27/2018] [Accepted: 07/03/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE To identify independent imaging features and establish a diagnostic algorithm for diagnosis of cystic fibrosis (CF)-associated liver disease (CFLD) in CF patients compared to controls using gadoxetic acid-enhanced MRI. METHODS A total of 90 adult patients were enrolled: 50 with CF, 40 controls. The CF group was composed of two subgroups: a retrospective test subgroup (n = 33) and a prospective validation subgroup (n = 17). Controls (patients with normal liver enzymes and only benign focal liver lesions) were divided accordingly (27:13). MRI variables, including quantitative and qualitative parameters, were used to distinguish CFLD from controls using clinical symptoms, laboratory tests and Debray criteria. Disease severity was classified according to Child-Pugh and Albumin-Bilirubin (ALBI) scores. Fifteen qualitative single-lesion CF descriptors were defined. Two readers independently evaluated the images. Univariate statistical analysis was performed to obtain significant imaging features that differentiate CF patients from controls. Through multivariate analysis using chi-squared automatic interaction detector (CHAID) methodology the most important descriptors were identified. Diagnostic performance was assessed by receiver-operating characteristic (ROC) analysis. RESULTS Three independent imaging descriptors distinguished CFLD from controls: (1) presence of altered gallbladder morphology; (2) periportal tracking; and (3) periportal fat deposition. Prospective validation of the classification algorithm demonstrated a sensitivity of 94.1% and specificity of 84.6% for discriminating CFLD from controls. Disease severity was well associated with the imaging features. CONCLUSIONS A short unenhanced MRI protocol can identify the three cardinal imaging features of CFLD. The hepatobiliary phase of gadoxetic acid-enhanced MRI can define CFLD progression. KEY POINTS • Using a multivariate classification analysis, we identified three independent imaging features, altered gallbladder morphology (GBAM), periportal tracking (PPT) and periportal fat deposition (PPFD), that could diagnose CFLD with high sensitivity, 94.1 % (95% CI: 71.3-99.9) and moderate specificity, 84.6 % (95% CI: 54.6-98.1). • Based upon the results of this study, gadoxetic acid-enhanced MRI with DWI is able to diagnose early-stage CFLD, as well as its progression.
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Affiliation(s)
- Sarah Poetter-Lang
- General Hospital of Vienna (AKH), Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Katharina Staufer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, General Hospital of Vienna (AKH), Medical University of Vienna, Vienna, Austria
| | - Pascal Baltzer
- General Hospital of Vienna (AKH), Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Dietmar Tamandl
- General Hospital of Vienna (AKH), Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Dina Muin
- General Hospital of Vienna (AKH), Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Nina Bastati
- General Hospital of Vienna (AKH), Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Emina Halilbasic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, General Hospital of Vienna (AKH), Medical University of Vienna, Vienna, Austria
| | - Jacqueline C Hodge
- General Hospital of Vienna (AKH), Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, General Hospital of Vienna (AKH), Medical University of Vienna, Vienna, Austria
| | - Lili Kazemi-Shirazi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, General Hospital of Vienna (AKH), Medical University of Vienna, Vienna, Austria
| | - Ahmed Ba-Ssalamah
- General Hospital of Vienna (AKH), Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria.
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Alexopoulou A, Pouriki S, Vasilieva L, Alexopoulos T, Filaditaki V, Gioka M, Diamantea F, Dourakis SP. Evaluation of noninvasive markers for the diagnosis of cystic fibrosis liver disease. Scand J Gastroenterol 2018; 53:1547-1552. [PMID: 30600723 DOI: 10.1080/00365521.2018.1534986] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 10/03/2018] [Accepted: 10/06/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVES In cystic fibrosis (CF), liver disease (LD) is the third leading cause of mortality. As liver biopsy was considered inconsistent in CFLD diagnosis, a combination of modalities were utilized in the conventional Debray criteria (DC). More recently, noninvasive liver fibrosis biomarkers were applied by Koh et al (New criteria-NC). In the current study, we aimed to evaluate noninvasive biomarkers for the CFLD diagnosis. METHODS Longitudinal data were collected from a cohort of genetically confirmed CF patients. CFLD was diagnosed by both DC and NC. Apart from transient elastography (TE) > 6.8 kPa, biomarkers incorporated in the NC included AST/ALT-ratio (AAR) ≥ 1, FIB-4 index ≥3.25 and APRI >0.50. RESULTS 62 patients with CF, [56.5% male, age at enrollment 25 (22-31) years], were prospectively followed-up for 33 (28-36) months. Sixteen (25.8%) and 27 (43.5%) patients met DC and NC, respectively. Twenty-four fulfilling NC had at least one positive biomarker (6 TE, 7 AAR, 6 both TE and AAR, 2 both APRI and AAR and 3 both APRI and TE). Thirteen (48.1%) had diffuse LD/cirrhosis by the NC and all had at least one additional parameter classifying them as CFLD. From the 14 (51.8%) with no-diffuse-LD, 64.3%, 14.3% and 21.4% had 2, 3 and 4 of the necessary modalities incorporated in NC, respectively, confirming their classification as CFLD. TE was 100% specific to rule in CFLD but had a moderate sensitivity. CONCLUSIONS NC were able to identify 17.7% more CFLD patients compared to DC. The multiple biomarkers incorporated in NC may enhance the ability to detect CFLD.
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Affiliation(s)
- Alexandra Alexopoulou
- a 2nd Department of Internal Medicine and Research Laboratory , Medical School, National and Kapodistrian University of Athens, Hippokration Hospital , Athens , Greece
| | - Sophia Pouriki
- a 2nd Department of Internal Medicine and Research Laboratory , Medical School, National and Kapodistrian University of Athens, Hippokration Hospital , Athens , Greece
| | - Larisa Vasilieva
- a 2nd Department of Internal Medicine and Research Laboratory , Medical School, National and Kapodistrian University of Athens, Hippokration Hospital , Athens , Greece
| | - Theodoros Alexopoulos
- a 2nd Department of Internal Medicine and Research Laboratory , Medical School, National and Kapodistrian University of Athens, Hippokration Hospital , Athens , Greece
| | - Vasiliki Filaditaki
- b Third Respiratory Medicine Department , Sismanogleio General Hospital , Athens , Greece
| | - Maria Gioka
- b Third Respiratory Medicine Department , Sismanogleio General Hospital , Athens , Greece
| | - Filia Diamantea
- b Third Respiratory Medicine Department , Sismanogleio General Hospital , Athens , Greece
| | - Spyros P Dourakis
- a 2nd Department of Internal Medicine and Research Laboratory , Medical School, National and Kapodistrian University of Athens, Hippokration Hospital , Athens , Greece
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Regard L, Martin C, Chassagnon G, Burgel PR. Acute and chronic non-pulmonary complications in adults with cystic fibrosis. Expert Rev Respir Med 2018; 13:23-38. [PMID: 30472915 DOI: 10.1080/17476348.2019.1552832] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Cystic fibrosis (CF) is a genetic disease that primarily affects the respiratory system and often leads to respiratory failure and premature death. Although pulmonary complications contribute to 85% of deaths, non-pulmonary complications are responsible for significant morbidity and mortality in adults with CF. Areas covered: This review summarizes acute and chronic non-pulmonary complications in CF patients, with emphasis on emerging complications and in the context of the current growth and aging of the CF adult population. It also addresses the potential benefits of CF transmembrane conductance regulator modulator therapy. Complications that occur after solid organ (e.g. lung and/or liver) transplantation have been excluded. The review is based on an extensive search of the available literature, using PubMed and international guidelines, and on the authors' clinical experience. Expert commentary: Acute non-pulmonary complications have been well described but should be recognized and managed carefully. Managing chronic non-pulmonary complications is an important and changing aspect of CF patient care, particularly with the emergence of novel complications in adults. Early detection of non-pulmonary complications is essential to the development of prevention and treatment strategies that aim to further improve the survival and health status of adult CF patients.
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Affiliation(s)
- Lucile Regard
- a Faculté de Médecine , Paris Descartes University , Sorbonne Paris Cité , Paris , France.,b Pulmonology Department , Cochin Hospital, AP-HP , Paris , France
| | - Clémence Martin
- a Faculté de Médecine , Paris Descartes University , Sorbonne Paris Cité , Paris , France.,b Pulmonology Department , Cochin Hospital, AP-HP , Paris , France
| | - Guillaume Chassagnon
- a Faculté de Médecine , Paris Descartes University , Sorbonne Paris Cité , Paris , France.,c Radiology Department , Cochin Hospital, AP-HP , Paris , France
| | - Pierre-Régis Burgel
- a Faculté de Médecine , Paris Descartes University , Sorbonne Paris Cité , Paris , France.,b Pulmonology Department , Cochin Hospital, AP-HP , Paris , France
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Ye W, Narkewicz MR, Leung DH, Karnsakul W, Murray KF, Alonso EM, Magee JC, Schwarzenberg SJ, Weymann A, Molleston JP. Variceal Hemorrhage and Adverse Liver Outcomes in Patients With Cystic Fibrosis Cirrhosis. J Pediatr Gastroenterol Nutr 2018; 66:122-127. [PMID: 28906321 PMCID: PMC5745284 DOI: 10.1097/mpg.0000000000001728] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Cirrhosis occurs in 5% to 10% of cystic fibrosis (CF) patients, often accompanied by portal hypertension. We analyzed 3 adverse liver outcomes, variceal bleeding (VB), liver transplant (LT), and liver-related death (LD), and risk factors for these in CF Foundation Patient Registry subjects with reported cirrhosis. METHODS We determined 10-year incidence rates for VB, LT, LD, and all-cause mortality (ACM), and examined risk factors using competing risk models and Cox-proportional hazard regression. RESULTS From 2003 to 2012, 943 participants (41% females, mean age 18.1 years) had newly reported cirrhosis; 24.7% required insulin, 85% had previous pseudomonas. Seventy-three subjects had reported VB: 38 with first VB and new cirrhosis reported simultaneously and 35 with VB after cirrhosis report. Ten-year cumulative VB, LT, and LD rates were 6.6% (95% confidence interval [CI]: 4.0, 9.1%), 9.9% (95% CI: 6.6%, 13.2%), and 6.9% (95% CI: 4.0%, 9.8%), respectively, with an ACM of 39.2% (95% CI: 30.8, 36.6%). ACM was not increased in subjects with VB compared to those without (hazard ratio [HR] 1.10, 95% CI: 0.59, 2.08). CF-related diabetes (HR: 3.141, 95% CI:1.56, 6.34) and VB (HR: 4.837, 95% CI: 2.33, 10.0) were associated with higher LT risk, whereas only worse lung function was associated with increased LD in multivariate analysis. Death rate among subjects with VB was 24% with LT and 20.4% with native liver. CONCLUSIONS VB is an uncommon complication of CF cirrhosis and can herald the diagnosis, but does not affect ACM. Adverse liver outcomes and ACM are frequent by 10 years after cirrhosis report.
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Affiliation(s)
- Wen Ye
- University of Michigan, Ann Arbor, MI
| | - Michael R Narkewicz
- Digestive Health Institute, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | - Daniel H Leung
- Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | | | - Karen F Murray
- Seattle Children's Hospital and University of Washington, Seattle, WA
| | | | | | | | | | - Jean P Molleston
- Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, IN
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Abstract
OBJECTIVES Hepatobiliary complications are a leading cause of morbidity and mortality in cystic fibrosis (CF) patients. Knowledge of the underlying pathological aspects and optimal clinical management is, however, sorely lacking. METHODS We provide a summary of the lectures given by international speakers at the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) monothematic conference on cystic fibrosis-related liver disease (CFLD) held in Paris in January 2016, to discuss the status of our current knowledge of liver disease in CF patients, to define the critical areas that need to be addressed, and to resolve actions to elucidate relevant mechanisms of disease to optimise future therapeutic options. CONCLUSIONS The need for a universal consensus on the definition of CFLD to clarify disease stage and to identify relevant biomarkers to assess disease severity was highlighted. A deeper understanding of the pathophysiology and prognostic factors for the long-term evolution of CFLD is fundamental to move forward and has a strong bearing on identifying potential treatments. Novel experimental models and new treatment options under investigation are discussed and offer hope for the near future of CFLD.
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Long-term challenges and perspectives of pre-adolescent liver disease. Lancet Gastroenterol Hepatol 2017; 2:435-445. [DOI: 10.1016/s2468-1253(16)30160-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/13/2016] [Accepted: 09/22/2016] [Indexed: 12/11/2022]
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Ronan NJ, Elborn JS, Plant BJ. Current and emerging comorbidities in cystic fibrosis. Presse Med 2017; 46:e125-e138. [PMID: 28554721 DOI: 10.1016/j.lpm.2017.05.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 01/09/2023] Open
Abstract
Cystic fibrosis transmembrane conductance regulator (CFTR) is expressed ubiquitously throughout the body. Thus, while respiratory manifestations dominate much of cystic fibrosis (CF) care, there are prominent multi-organ manifestations and comorbidities. In the general population, the number of comorbidities increases with aging. Few illnesses have experienced such a dramatic improvement in survival as CF, which has been transformed from an illness of childhood death to one of adult survival. Hence, as longevity increases in CF, it is paralleled by an increasing number of patients with multicomplex comorbidities availing of care from adult CF multi-disciplinary teams. This review gives an overview of the traditional CF associated comorbidities and those emerging in an aging adult cohort. While historically the treatment of CF focused on the consequences of CFTR dysfunction, the recent advent of CFTR modulators with the potential to enhance CFTR function represents an opportunity to potentially reverse or delay the development of some of the comorbidities associated with CF. Where evidence is available for the impact of CFTR modulatory therapy, namely ivacaftor on comorbidities in CF, this is highlighted.
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Affiliation(s)
- Nicola J Ronan
- Cork university hospital, university college Cork, Cork adult cystic fibrosis centre, HRB clinical research facility, Wilton,T12 DFK4 Cork, Ireland
| | - Joseph Stuart Elborn
- London and Queen's university Belfast, National heart and lung institute, Imperial College, Royal Brompton hospital, London, United Kingdom
| | - Barry J Plant
- Cork university hospital, university college Cork, Cork adult cystic fibrosis centre, HRB clinical research facility, Wilton,T12 DFK4 Cork, Ireland.
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Imaging the Abdominal Manifestations of Cystic Fibrosis. Int J Hepatol 2017; 2017:5128760. [PMID: 28250993 PMCID: PMC5303593 DOI: 10.1155/2017/5128760] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 12/17/2016] [Accepted: 01/09/2017] [Indexed: 02/07/2023] Open
Abstract
Cystic fibrosis (CF) is a multisystem disease with a range of abdominal manifestations including those involving the liver, pancreas, and kidneys. Recent advances in management of the respiratory complications of the disease has led to a greater life expectancy in patients with CF. Subsequently, there is increasing focus on the impact of abdominal disease on quality of life and survival. Liver cirrhosis is the most important extrapulmonary cause of death in CF, yet significant challenges remain in the diagnosis of CF related liver disease. The capacity to predict those patients at risk of developing cirrhosis remains a significant challenge. We review representative abdominal imaging findings in patients with CF selected from the records of two academic health centres, with a view to increasing familiarity with the abdominal manifestations of the disease. We review their presentation and expected imaging findings, with a focus on the challenges facing diagnosis of the hepatic manifestations of the disease. An increased familiarity with these abdominal manifestations will facilitate timely diagnosis and management, which is paramount to further improving outcomes for patients with cystic fibrosis.
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Leung D, Narang A, Minard C, Hiremath G, Goss J, Shepherd R. A 10-Year united network for organ sharing review of mortality and risk factors in young children awaiting liver transplantation. Liver Transpl 2016; 22:1584-1592. [PMID: 27541809 PMCID: PMC5083224 DOI: 10.1002/lt.24605] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 08/04/2016] [Indexed: 12/21/2022]
Abstract
Young children < 2 years of age with chronic end-stage liver disease (YC2) are a uniquely vulnerable group listed for liver transplantation, characterized by a predominance of biliary atresia (BA). To investigate wait-list mortality, associated risk factors, and outcomes of YC2, we evaluated United Network for Organ Sharing registry data from April 2003 to March 2013 for YC2 listed for deceased donor transplant (BA = 994; other chronic liver disease [CLD] = 221). Overall, wait-list mortality among YC2 was 12.4% and posttransplant mortality was 8%, accounting for an overall postlisting mortality of 19.6%. YC2 demonstrated 12.2%, 18.7%, and 20.6% wait-list mortality by 90, 180, and 270 days, respectively. YC2 with CLD demonstrated significantly higher wait-list mortality compared with BA among YC2 (23.9% versus 9.8%; P < 0.05). Multivariate analyses revealed that listing Pediatric End-Stage Liver Disease [PELD] > 21 (hazard ratio [HR], 3.2; 95% confidence interval [CI], 1.6-6.5), lack of exception (HR, 5.8; 95% CI, 2.8-11.8), listing height < 60.6 cm (HR, 2.1; 95% CI, 1.4-3.1), listing weight > 10 kg (HR, 3.8; 95% CI, 1.5-9.2), and initial creatinine > 0.5 (HR, 6.8; 95% CI, 3.4-13.5) were independent risk factors for YC2 wait-list mortality (P < 0.005 for all). Adjusting for all variables, the risk of death among CLD patients was 2 (95% CI, 1.3-3.1) times greater than patients with BA + surgery (presumed Kasai). Furthermore, the risk of death in BA without surgery was 1.9 (95% CI, 1‐3.4) times greater than BA with presumed Kasai. Our data highlight unacceptably high wait-list and early post-liver transplant mortality in YC2 not predicted by PELD and suggest key risk factors deserving of further study in this age group. Liver Transplantation 22 1584-1592 2016 AASLD.
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Affiliation(s)
- D.H. Leung
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX
| | - A. Narang
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - C.G. Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Houston, TX
| | - G. Hiremath
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - J.A. Goss
- Division of Abdominal Transplant Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - R. Shepherd
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX
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42
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Management of pancreatic, gastrointestinal and liver complications in adult cystic fibrosis. Rev Mal Respir 2015; 32:566-85. [DOI: 10.1016/j.rmr.2014.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 12/09/2014] [Indexed: 01/27/2023]
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Noninvasive methods, including transient elastography, for the detection of liver disease in adults with cystic fibrosis. Can J Gastroenterol Hepatol 2015; 29:139-44. [PMID: 25855877 PMCID: PMC4399373 DOI: 10.1155/2015/138530] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Liver disease is the third leading cause of mortality in patients with cystic fibrosis (CF). However, detection of CF-associated liver disease (CFLD) is challenging. OBJECTIVE To evaluate the diagnostic performance of noninvasive methods for the detection of CFLD with a focus on transient elastography (TE). METHODS Patients at the Adult CF Clinic of Calgary and Southern Alberta (n=127) underwent liver stiffness measurement (LSM) by TE using the FibroScan (FS, Ecosens, France) M probe; aspartate aminotransferase to platelet ratio index (APRI) and FibroTest (FT) scores were also calculated. The diagnostic performance of these tools for the detection of CFLD (defined as two or more the following criteria: abnormal liver biochemistry, hepatomegaly or sonographic abnormalities other than steatosis) were compared using the area under ROC curves. RESULTS Forty-seven percent of the cohort was male. The median age was 27 years (interquartile range [IQR] 22 to 37 years) and body mass index 21 kg⁄m(2) (IQR 19 kg⁄m(2) to 23 kg⁄m(2)); 25% of patients were on ursodeoxycholic acid and 12% had undergone lung transplantation. The prevalence of CFLD was 14% (n=18). FS was successful in all patients; one (0.8%) patient had poorly reliable results (IQR⁄M >30% and LSM ≥7.1 kPa). Compared with patients without CFLD (n=109), individuals with CFLD had higher median LSM according to FS (3.9 kPa [IQR 3.4 to 4.9 kPa] versus 6.4 kPa [IQR 4.4 to 8.0 kPa]), APRI (0.24 [IQR 0.17 to 0.31] versus 0.50 [IQR 0.22 to 1.18]) and FT scores (0.08 [IQR 0.05 to 1.5] versus 0.18 [IQR 0.11 to 0.35]; all P<0.05). Area under ROC curve for FS, APRI and FT for the detection of CFLD were 0.78 (95% CI 0.65 to 0.92), 0.72 (95% CI 0.56 to 0.87) and 0.76 (95% CI 0.62 to 0.90) (P not significant). At a threshold of >5.2 kPa, the sensitivity, specificity, positive and negative predictive values of LSM according to FS for detecting CFLD were 67%, 83%, 40% and 94%, respectively. CONCLUSIONS FS, APRI and FT were useful noninvasive methods for detecting CFLD in adults.
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Staufer K, Halilbasic E, Trauner M, Kazemi-Shirazi L. Cystic fibrosis related liver disease--another black box in hepatology. Int J Mol Sci 2014; 15:13529-49. [PMID: 25093717 PMCID: PMC4159809 DOI: 10.3390/ijms150813529] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/10/2014] [Accepted: 07/16/2014] [Indexed: 02/07/2023] Open
Abstract
Due to improved medical care, life expectancy in patients with cystic fibrosis (CF) has veritably improved over the last decades. Importantly, cystic fibrosis related liver disease (CFLD) has become one of the leading causes of morbidity and mortality in CF patients. However, CFLD might be largely underdiagnosed and diagnostic criteria need to be refined. The underlying pathomechanisms are largely unknown, and treatment strategies with proven efficacy are lacking. This review focuses on current invasive and non-invasive diagnostic standards, the current knowledge on the pathophysiology of CFLD, treatment strategies, and possible future developments.
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Affiliation(s)
- Katharina Staufer
- Division of Transplantation, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
| | - Emina Halilbasic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
| | - Lili Kazemi-Shirazi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
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Rowland M, Gallagher C, Gallagher CG, Laoide RÓ, Canny G, Broderick AM, Drummond J, Greally P, Slattery D, Daly L, McElvaney NG, Bourke B. Outcome in patients with cystic fibrosis liver disease. J Cyst Fibros 2014; 14:120-6. [PMID: 24917116 DOI: 10.1016/j.jcf.2014.05.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 04/16/2014] [Accepted: 05/10/2014] [Indexed: 01/24/2023]
Abstract
BACKGROUND Liver disease is an important complication in CF. AIMS To determine if CFLD is a risk factor for mortality in CF, and which baseline characteristics predict all-cause mortality. METHODS Irish children with CFLD, and their age and gender matched controls were enrolled at baseline and reviewed after 10years to determine which characteristics predict mortality. RESULTS 72/84 (85.71%) participants were followed, (mean age Cases 21.71yrs SD 6.5, CF controls 23.62 SD 5.6, 22 (61%) males), with no difference in duration of follow-up. Nineteen participants (26.4%) died, 38.9% (14/36) with CFLD and 13.89% (5/36) CF controls (Odds Ratio (OR) 3.94 95% CI:1.23-12.56 p=0.005). In logistic regression, liver disease (OR 4.28 95% CI 1.07-17.16) female gender (OR 12.25 95% CI 2.37-63.24), reduced pulmonary function, (OR 5.11 95% CI 1.09-23.81) were each independent risk factors for mortality in CF. CONCLUSIONS Liver disease is an independent risk factor for mortality in CF.
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Affiliation(s)
- Marion Rowland
- School of Medicine and Medical Science University College Dublin, Catherine McAuley Research Centre, Nelson Street, Dublin 7, Ireland.
| | - Cliona Gallagher
- School of Medicine and Medical Science University College Dublin, Catherine McAuley Research Centre, Nelson Street, Dublin 7, Ireland
| | - Charles G Gallagher
- St Vincent's University Hospital Elm Park, Dublin 4, Ireland; School of Medicine and Medical Science, Health Science Centre, Belfield, Dublin 4, Ireland
| | - Risteárd Ó Laoide
- St Vincent's University Hospital Elm Park, Dublin 4, Ireland; School of Medicine and Medical Science, Health Science Centre, Belfield, Dublin 4, Ireland
| | - Gerard Canny
- Our Lady's Children's Hospital Crumlin, Dublin 12, Ireland
| | - Anne Marie Broderick
- School of Medicine and Medical Science, Health Science Centre, Belfield, Dublin 4, Ireland; Our Lady's Children's Hospital Crumlin, Dublin 12, Ireland
| | - Jennifer Drummond
- School of Medicine and Medical Science University College Dublin, Catherine McAuley Research Centre, Nelson Street, Dublin 7, Ireland
| | - Peter Greally
- The National Children's Hospital, Tallaght, Dublin 14, Ireland
| | - Dubhfeasa Slattery
- St Vincent's University Hospital Elm Park, Dublin 4, Ireland; The Children's University Hospital, Temple Street, Dublin 7, Ireland
| | - Leslie Daly
- UCD School of Public Health, Physiotherapy, and Population Science, Dublin 4, Ireland
| | - Noel G McElvaney
- Beaumont Hospital, Dublin 9, Ireland; Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Billy Bourke
- St Vincent's University Hospital Elm Park, Dublin 4, Ireland; Our Lady's Children's Hospital Crumlin, Dublin 12, Ireland
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Leeuwen L, Magoffin AK, Fitzgerald DA, Cipolli M, Gaskin KJ. Cholestasis and meconium ileus in infants with cystic fibrosis and their clinical outcomes. Arch Dis Child 2014; 99:443-7. [PMID: 24436365 DOI: 10.1136/archdischild-2013-304159] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To identify the incidence and outcomes of cholestasis and meconium ileus (MI) in infants with cystic fibrosis (CF). DESIGN Retrospective cohort study. SETTING Single-centre study. PATIENTS From January 1986 to December 2011, 401 infants with CF (69 with MI) presented to our centre. MAIN OUTCOME MEASUREMENTS (1) incidence of cholestasis, (2) identification of risk factors for cholestasis, (3) association between the presence of cholestasis and MI and the development of clinically significant CF-associated liver disease (CFLD) defined as multilobular cirrhosis with portal hypertension. RESULTS Cholestasis occurred in 23 of 401 infants (5.7%). There was a significantly higher incidence of cholestasis in infants with MI (27.1%) compared to those without MI (1.2%) (p<0.001). Infants with MI had a 30.36-fold increased risk of developing cholestasis compared to those without MI (p<0.001). Cholestasis resolved in all children, at a median (range) age of 9.2 (0.8-53.2) months in the MI group and 10.2 (2.0-19.4) months in the non-MI group. The majority of cholestatic infants (87.0%) and infants with MI (92.8%) did not develop clinically significant CFLD, not significantly different than either the 93.9% of non-cholestatic infants nor the 93.7% infants without MI. CONCLUSIONS Cholestasis is an uncommon condition in CF affecting only 5.7% of the screened newborn CF population. The greatest risk factor for developing cholestasis is the presence of MI. However, the presence of MI appears not to be associated with the development of CFLD. An effect of neonatal cholestasis on the development of CFLD cannot be excluded by this study.
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Affiliation(s)
- Lisette Leeuwen
- Department of Respiratory Medicine, The Children's Hospital at Westmead, , Sydney, Australia
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Abstract
The survival of patients with cystic fibrosis (CF) has progressively increased over recent decades, largely attributable to early diagnosis through newborn screening and advances in nutritional and respiratory care. As the life expectancy of patients with CF has improved, non-respiratory complications such as liver disease have become increasingly recognized. Biochemical derangements of liver enzymes in CF are common and may be attributed to a number of specific hepatobiliary abnormalities. Among them, Cystic Fibrosis-associated Liver Disease (CFLD) is clinically the most significant hepatic complication and is believed to have a significant impact on morbidity and mortality. However, there remains much conjecture about the extent of the adverse prognostic implications that a diagnosis of CFLD has on clinical outcomes. The purpose of this review is to give an overview of the current knowledge regarding liver disease in children with CF.
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Affiliation(s)
- Lisette Leeuwen
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia; Medical School, University of Groningen, Groningen, The Netherlands
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia; Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Australia
| | - Kevin J Gaskin
- Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Australia; Department of Gastroenterology, The Children's Hospital at Westmead, Sydney, Australia; James Fairfax Institute of Paediatric Nutrition, University of Sydney, Sydney, Australia.
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Khanna R, Alam S, Rastogi A, Sharma CB. Neonatal cholestasis with ductal paucity and steatosis. Indian Pediatr 2013; 50:316-20. [DOI: 10.1007/s13312-013-0073-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Flass T, Narkewicz MR. Cirrhosis and other liver disease in cystic fibrosis. J Cyst Fibros 2013; 12:116-24. [PMID: 23266093 PMCID: PMC3883947 DOI: 10.1016/j.jcf.2012.11.010] [Citation(s) in RCA: 135] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 11/14/2012] [Accepted: 11/15/2012] [Indexed: 12/25/2022]
Affiliation(s)
- Thomas Flass
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics University of Colorado School of Medicine and The Pediatric Liver Center, Children's Hospital Colorado, Aurora, CO, USA
| | - Michael R Narkewicz
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics University of Colorado School of Medicine and The Pediatric Liver Center, Children's Hospital Colorado, Aurora, CO, USA.
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Chen X, Liu C, Lu Y, Yang Z, Lv Z, Xu Q, Pan Q, Lu L. Paeoniflorin regulates macrophage activation in dimethylnitrosamine-induced liver fibrosis in rats. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2012; 12:254. [PMID: 23237422 PMCID: PMC3575304 DOI: 10.1186/1472-6882-12-254] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Accepted: 12/05/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Macrophages in other organs (e.g. kidneys, lungs, and spleen, et. al) have rarely been reported in the development of liver fibrosis. Therefore, it is important to investigate macrophage activation in the main organs in liver fibrosis. We investigated the potential antifibrogenic effects of paeoniflorin (PF) in a dimethylnitrosamine (DMN)-induced rat model with special focus on inhibiting macrophage activation in the main organs. METHODS Rat hepatic fibrosis was induced by treatment with DMN three times weekly over a 4-week period. DMN rats were treated with water, PF, or gadolinium chloride (GdCl3) from the beginning of the 3rd week. The expression of CD68, marker of macrophage, was investigated using immunohistochemical, real-time PCR, and western blot analysis. RESULTS Hepatic hydroxyproline content markedly decreased and histopathology improved in the DMN-PF rats. Expression of desmin and collagen 1 decreased notably in DMN-PF liver. CD68 expression in the liver, spleen and kidney increased markedly after 2 weeks but decreased in DMN-water rats. PF and GdCl3 decreased CD68 expression in the liver and spleen and there was no effect on kidney. CD68 expression in the lung increased gradually during the course of DMN-induced liver fibrosis, and PF inhibited CD68 expression in the lung significantly while GdCl3 increased CD68 markedly. Expression of tumor necrosis factor (TNF-α) was decreased significantly by GdCl3 in the liver, as revealed by real-time PCR analysis. However, GdCl3 could not decrease TNF-α level in the serum by enzyme linked immunosorbent assay (ELISA). CONCLUSIONS Macrophage activation was disrupted in the liver, spleen, lung and kidney during development of DMN-induced liver fibrosis. PF administration attenuated DMN-induced liver fibrosis at least in part by regulating macrophage disruption in the main organs.
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Affiliation(s)
- Xiaorong Chen
- Department of Traditional Chinese Medicine, Shanghai Public Health Clinical Center, 2901 Caolang Road, Jin Shan District, Shanghai, 201508, China
- Key Laboratory of Infectious Diseases of State Administration of Traditional Chinese Medicine (clinical base), Shanghai, 201508, China
| | - Cheng Liu
- Department of Traditional Chinese Medicine, Shanghai Public Health Clinical Center, 2901 Caolang Road, Jin Shan District, Shanghai, 201508, China
- Key Laboratory of Infectious Diseases of State Administration of Traditional Chinese Medicine (clinical base), Shanghai, 201508, China
- Scientific Research Center, Shanghai Public Health Clinical Center, Shanghai, 201508, China
| | - Yunfei Lu
- Department of Traditional Chinese Medicine, Shanghai Public Health Clinical Center, 2901 Caolang Road, Jin Shan District, Shanghai, 201508, China
- Key Laboratory of Infectious Diseases of State Administration of Traditional Chinese Medicine (clinical base), Shanghai, 201508, China
| | - Zongguo Yang
- Department of Traditional Chinese Medicine, Shanghai Public Health Clinical Center, 2901 Caolang Road, Jin Shan District, Shanghai, 201508, China
| | - Zhen Lv
- Department of Traditional Chinese Medicine, Shanghai Public Health Clinical Center, 2901 Caolang Road, Jin Shan District, Shanghai, 201508, China
| | - Qingnian Xu
- Department of Traditional Chinese Medicine, Shanghai Public Health Clinical Center, 2901 Caolang Road, Jin Shan District, Shanghai, 201508, China
- Key Laboratory of Infectious Diseases of State Administration of Traditional Chinese Medicine (clinical base), Shanghai, 201508, China
| | - Qi Pan
- Department of Traditional Chinese Medicine, Shanghai Public Health Clinical Center, 2901 Caolang Road, Jin Shan District, Shanghai, 201508, China
- Key Laboratory of Infectious Diseases of State Administration of Traditional Chinese Medicine (clinical base), Shanghai, 201508, China
| | - Lingqing Lu
- Department of Traditional Chinese Medicine, Shanghai Public Health Clinical Center, 2901 Caolang Road, Jin Shan District, Shanghai, 201508, China
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