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Gómez-Mellado VE, Ho-Mok KS, van der Mark VA, van der Wel NN, Grootemaat AE, Verhoeven AJ, Elferink RPJO, Paulusma CC. The phospholipid flippase ATP8B1 is required for lysosomal fusion in macrophages. Cell Biochem Funct 2022; 40:914-925. [PMID: 36169099 PMCID: PMC10087937 DOI: 10.1002/cbf.3752] [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: 04/20/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 12/15/2022]
Abstract
ATP8B1 is a phospholipid flippase and member of the type 4 subfamily of P-type ATPases (P4-ATPase) subfamily. P4-ATPases catalyze the translocation of phospholipids across biological membranes, ensuring proper membrane asymmetry, which is crucial for membrane protein targeting and activity, vesicle biogenesis, and barrier function. Here we have investigated the role of ATP8B1 in the endolysosomal pathway in macrophages. Depletion of ATP8B1 led to delayed degradation of content in the phagocytic pathway and in overacidification of the endolysosomal system. Furthermore, ATP8B1 knockdown cells exhibited large multivesicular bodies filled with intraluminal vesicles. Similar phenotypes were observed in CRISPR-generated ATP8B1 knockout cells. Importantly, induction of autophagy led to accumulation of autophagosomes in ATP8B1 knockdown cells. Collectively, our results support a novel role for ATP8B1 in lysosomal fusion in macrophages, a process crucial in the terminal phase of endolysosomal degradation.
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Affiliation(s)
- Valentina E Gómez-Mellado
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kam S Ho-Mok
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent A van der Mark
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole N van der Wel
- Department of Medical Biology, Electron Microscopy Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Anita E Grootemaat
- Department of Medical Biology, Electron Microscopy Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Arthur J Verhoeven
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ronald P J Oude Elferink
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Coen C Paulusma
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Gómez-Mellado VE, Chang JC, Ho-Mok KS, Bernardino Morcillo C, Kersten RHJ, Oude Elferink RPJ, Verhoeven AJ, Paulusma CC. ATP8B1 Deficiency Results in Elevated Mitochondrial Phosphatidylethanolamine Levels and Increased Mitochondrial Oxidative Phosphorylation in Human Hepatoma Cells. Int J Mol Sci 2022; 23:ijms232012344. [PMID: 36293199 PMCID: PMC9604224 DOI: 10.3390/ijms232012344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/20/2022] Open
Abstract
ATP8B1 is a phospholipid flippase that is deficient in patients with progressive familial intrahepatic cholestasis type 1 (PFIC1). PFIC1 patients suffer from severe liver disease but also present with dyslipidemia, including low plasma cholesterol, of yet unknown etiology. Here we show that ATP8B1 knockdown in HepG2 cells leads to a strong increase in the mitochondrial oxidative phosphorylation (OXPHOS) without a change in glycolysis. The enhanced OXPHOS coincides with elevated low-density lipoprotein receptor protein and increased mitochondrial fragmentation and phosphatidylethanolamine levels. Furthermore, expression of phosphatidylethanolamine N-methyltransferase, an enzyme that catalyzes the conversion of mitochondrial-derived phosphatidylethanolamine to phosphatidylcholine, was reduced in ATP8B1 knockdown cells. We conclude that ATP8B1 deficiency results in elevated mitochondrial PE levels that stimulate mitochondrial OXPHOS. The increased OXPHOS leads to elevated LDLR levels, which provides a possible explanation for the reduced plasma cholesterol levels in PFIC1 disease.
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Affiliation(s)
- Valentina E. Gómez-Mellado
- Amsterdam UMC, University of Amsterdam, Tytgat Institute for Liver and Intestinal Research, Meibergdreef 69, 1105 BK Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, 1105 AZ Amsterdam, The Netherlands
| | - Jung-Chin Chang
- Amsterdam UMC, University of Amsterdam, Tytgat Institute for Liver and Intestinal Research, Meibergdreef 69, 1105 BK Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, 1105 AZ Amsterdam, The Netherlands
- Department of Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CS Utrecht, The Netherlands
| | - Kam S. Ho-Mok
- Amsterdam UMC, University of Amsterdam, Tytgat Institute for Liver and Intestinal Research, Meibergdreef 69, 1105 BK Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, 1105 AZ Amsterdam, The Netherlands
| | - Carmen Bernardino Morcillo
- Amsterdam UMC, University of Amsterdam, Tytgat Institute for Liver and Intestinal Research, Meibergdreef 69, 1105 BK Amsterdam, The Netherlands
| | - Remco H. J. Kersten
- Amsterdam UMC, University of Amsterdam, Tytgat Institute for Liver and Intestinal Research, Meibergdreef 69, 1105 BK Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, 1105 AZ Amsterdam, The Netherlands
| | - Ronald P. J. Oude Elferink
- Amsterdam UMC, University of Amsterdam, Tytgat Institute for Liver and Intestinal Research, Meibergdreef 69, 1105 BK Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, 1105 AZ Amsterdam, The Netherlands
| | - Arthur J. Verhoeven
- Amsterdam UMC, University of Amsterdam, Tytgat Institute for Liver and Intestinal Research, Meibergdreef 69, 1105 BK Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, 1105 AZ Amsterdam, The Netherlands
| | - Coen C. Paulusma
- Amsterdam UMC, University of Amsterdam, Tytgat Institute for Liver and Intestinal Research, Meibergdreef 69, 1105 BK Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, 1105 AZ Amsterdam, The Netherlands
- Correspondence:
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Altay D, Gorukmez O, Arslan D. Coexistence of Three Different Mutations in a Male Infant: neurofibromatosis Type 1, Progressive Familial Intrahepatic Cholestasis Type 2 and LPIN3. Fetal Pediatr Pathol 2022; 41:293-298. [PMID: 32597698 DOI: 10.1080/15513815.2020.1783405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
IntroductionThe coexistence of progressive familial intrahepatic cholestasis type 2, failure to thrive due to an LPIN3 mutation, and stigmata of neonatal neurofibromatosis represents a complex diagnostic challenge. Case report: We present a child with cholestasis requiring hepatic transplantation, explained by the progressive familial intrahepatic cholestasis type 2, failure to thrive could be contributed to by the LPIN3 mutation, and skin findings along with the family history of the patient was due to neurofibromatosis type 1. Conclusion: Our case illustrates the complexities of multiple genetic mutations in a child.
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Affiliation(s)
- Derya Altay
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Orhan Gorukmez
- Department of Genetics, Bursa Yüksek İhtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Duran Arslan
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Erciyes University Faculty of Medicine, Kayseri, Turkey
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Mighiu C, O'Hara S, Ferri Grazzi E, Murray KF, Schattenberg JM, Ventura E, Karakaidos M, Taylor A, Brrang H, Dhawan A, Willemse J, Finnegan A. Impact of progressive familial intrahepatic cholestasis on caregivers: caregiver-reported outcomes from the multinational PICTURE study. Orphanet J Rare Dis 2022; 17:32. [PMID: 35109890 PMCID: PMC8809495 DOI: 10.1186/s13023-022-02177-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/16/2022] [Indexed: 01/01/2023] Open
Abstract
Background Progressive familial intrahepatic cholestasis (PFIC) is a spectrum of rare genetic diseases characterized by inadequate bile secretion that requires substantial ongoing care, though little research is published in this area. We report health-related quality of life (HRQoL) and work productivity outcomes from the retrospective, cross-sectional PICTURE study investigating the burden of PFIC on caregivers. Information from caregivers of patients with PFIC 1 or 2 in Germany, the United Kingdom and the United States from September 2020 to March 2021 was included.
Results The PICTURE study sample comprised HRQoL responses from 22 PFIC caregivers. Patients were on average 8.2 years old; most caregivers were 30–49 years old (68%) and mothers (77%). Median CarerQoL-7D score was 67.7/100; mean CarerQoL-VAS score for general happiness was 5.7/10 (SD 2.1). Most caregivers reported fulfilment in their caregiving responsibilities, but problems with mental and physical health, finances, and relationships. When stratified by patient’s PFIC type, mean CarerQoL-7D and CarerQoL-VAS scores suggested worse HRQoL outcomes with PFIC2 versus PFIC1 (59.4 vs. 71.2, and 5.3 vs. 6.5, respectively). Additionally, more caregivers reported impact on sleep in the PFIC2 versus PFIC1 subgroup (93% vs. 75%). When stratified by history of PFIC-related surgeries, mean CarerQoL-7D and VAS scores were higher among those whose children had no specified surgeries (67.7 vs. 59.0/100 and 6.2 vs. 5.2/10, respectively). Nearly all caregivers reported an impact of caregiving responsibilities on sleeping (86%) and on personal relationships (82%). No caregivers reported having formal care support. Most caregivers were employed (73%); a third reported mean productivity loss of 12.9 days (SD 19.3) over the last 3 months, and a mean of 2.8 (SD 9.5) missed years of employment during their career. A higher number of workdays were missed by PFIC 2 caregivers compared to PFIC1 over last 3 months (16 days vs. 3 days). Conclusions The PICTURE study has demonstrated the prevalent, comprehensive, and meaningful burden that caring for an individual with PFIC has on caregivers. Despite fulfilment from caregiving, the breadth and depth of these responsibilities reduced caregiver reported HRQoL including mental and physical health, productivity, career prospects, sleep, relationships and finances. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02177-0.
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Affiliation(s)
| | | | | | - Karen F Murray
- Pediatric Institute, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Jörn M Schattenberg
- University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Emily Ventura
- PFIC Advocacy and Resource Network, Stanton, KY, USA
| | | | | | | | - Anil Dhawan
- Pediatric Liver GI and Nutrition Center, King's College Hospital, London, UK
| | - Jose Willemse
- Dutch Liver Patient Association (NLV), Hoogland, The Netherlands
| | - Alan Finnegan
- Faculty of Health and Social Care, University of Chester, Chester, UK
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Bolia R, Goel AD, Sharma V, Srivastava A. Biliary diversion in progressive familial intrahepatic cholestasis: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2022; 16:163-172. [PMID: 35051344 DOI: 10.1080/17474124.2022.2032660] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Biliary diversion (BD) is indicated in progressive familial intrahepatic cholestasis (PFIC) with refractory pruritus. Three types-partial external biliary drainage (PEBD), partial internal biliary drainage (PIBD), and ileal exclusion (IE) are described, with no consensus about the relative efficacy of these procedures. METHODS PubMed, Scopus, and Google Scholar were searched for publications on PFIC and BD. Improvement in pruritus, serum bile acid (BA), and need for liver transplantation (LT) were compared between the various BD procedures. RESULTS 25 studies [424 children (PEBD-301, PIBD-93, IE-30)] were included. Pruritus resolved in 59.5% [PIBD:72% (95%CI 43-96%), PEBD:57% (95%CI 43-71%) and IE:48% (95%CI 14-82%)] cases. Significant overlap in confidence intervals indicated no significant differences. Absolute decrease in BA (AUROC-0.72) and bilirubin (AUROC-0.69) discriminated responders and non-responders. Eventually, 27% required LT: PIBD 10.7%, PEBD32%, IE 27%. The post-operative BA (AUROC-0.9) and bilirubin (AUROC-0.85) determined need for LT. Complications were commoner in PEBD than PIBD (38% vs 21.8%: p=0.02). CONCLUSION 59.5% children have pruritus relief after BD and 27% need LT. PIBD has lower complications and LT requirement than PEBD. However, this requires cautious interpretation as the 2 groups differed in PFIC type and follow-up duration.
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Affiliation(s)
- Rishi Bolia
- Division of Paediatric Gastroenterology, Department of Paediatrics, All India Institute of Medical Sciences, Rishikesh, India
| | - Akhil Dhanesh Goel
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Vishakha Sharma
- Division of Paediatric Gastroenterology, Department of Paediatrics, All India Institute of Medical Sciences, Rishikesh, India
| | - Anshu Srivastava
- Department of Paediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Masahata K, Ueno T, Bessho K, Kodama T, Tsukada R, Saka R, Tazuke Y, Miyagawa S, Okuyama H. Clinical outcomes of surgical management for rare types of progressive familial intrahepatic cholestasis: a case series. Surg Case Rep 2022; 8:10. [PMID: 35024979 PMCID: PMC8758805 DOI: 10.1186/s40792-022-01365-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/10/2022] [Indexed: 12/14/2022] Open
Abstract
Background Progressive familial intrahepatic cholestasis (PFIC) is a heterogeneous group of genetic autosomal recessive diseases that cause severe cholestasis, which progresses to cirrhosis and liver failure, in infancy or early childhood. We herein report the clinical outcomes of surgical management in patients with four types of PFIC. Case presentation Six patients diagnosed with PFIC who underwent surgical treatment between 1998 and 2020 at our institution were retrospectively assessed. Living-donor liver transplantation (LDLT) was performed in 5 patients with PFIC. The median age at LDLT was 4.8 (range: 1.9–11.4) years. One patient each with familial intrahepatic cholestasis 1 (FIC1) deficiency and bile salt export pump (BSEP) deficiency died after LDLT, and the four remaining patients, one each with deficiency of FIC1, BSEP, multidrug resistance protein 3 (MDR3), and tight junction protein 2 (TJP2), survived. One FIC1 deficiency recipient underwent LDLT secondary to deterioration of liver function, following infectious enteritis. Although he underwent LDLT accompanied by total external biliary diversion, the patient died because of PFIC-related complications. The other patient with FIC1 deficiency had intractable pruritus and underwent partial internal biliary diversion (PIBD) at 9.8 years of age, pruritus largely resolved after PIBD. One BSEP deficiency recipient, who had severe graft damage, experienced recurrence of cholestasis due to the development of antibodies against BSEP after LDLT, and eventually died due to graft failure. The other patient with BSEP deficiency recovered well after LDLT and there was no evidence of posttransplant recurrence of cholestasis. In contrast, recipients with MDR3 or TJP2 deficiency showed good courses and outcomes after LDLT. Conclusions Although LDLT was considered an effective treatment for PFIC, the clinical courses and outcomes after LDLT were still inadequate in patients with FIC1 and BSEP deficiency. LDLT accompanied by total biliary diversion may not be as effective for patients with FIC1 deficiency.
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Affiliation(s)
- Kazunori Masahata
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takehisa Ueno
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Kazuhiko Bessho
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tasuku Kodama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Ryo Tsukada
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Ryuta Saka
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shuji Miyagawa
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Long-Term Outcome after Liver Transplantation for Progressive Familial Intrahepatic Cholestasis. MEDICINA-LITHUANIA 2021; 57:medicina57080854. [PMID: 34441060 PMCID: PMC8400732 DOI: 10.3390/medicina57080854] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/14/2021] [Accepted: 08/16/2021] [Indexed: 12/12/2022]
Abstract
Background and Objectives: Progressive familial intrahepatic cholestasis (PFIC) is a rare autosomal recessive inherited disease divided into five types (PFIC 1-5). Characteristic for all types is early disease onset, which may result clinically in portal hypertension, fibrosis, cirrhosis, hepatocellular carcinoma (HCC), and extrahepatic manifestations. Liver transplantation (LT) is the only successful treatment approach. Our aim is to present the good long-term outcomes after liver transplantation for PFIC1, focusing on liver function as well as the occurrence of extrahepatic manifestation after liver transplantation. Materials and Methods: A total of seven pediatric patients with PFIC1 underwent liver transplantation between January 1999 and September 2019 at the Department of Surgery, Charité Campus Virchow Klinikum and Charité Campus Mitte of Charité-Universitätsmedizin Berlin. Long-term follow-up data were collected on all patients, specifically considering liver function and extrahepatic manifestations. Results: Seven (3.2%) recipients were found from a cohort of 219 pediatric patients. Two of the seven patients had multilocular HCC in cirrhosis. Disease recurrence or graft loss did not occur in any patient. Two patients (male, siblings) had persistently elevated liver parameters but showed excellent liver function. Patient and graft survival during long-term follow-up was 100%, and no severe extrahepatic manifestations requiring hospitalization or surgery occurred. We noted a low complication rate during long-term follow-up and excellent patient outcome. Conclusions: PFIC1 long-term follow-up after LT shows promising results for this rare disease. In particular, the clinical relevance of extrahepatic manifestations seems acceptable, and graft function seems to be barely affected. Further multicenter studies are needed to analyze the clinically inhomogeneous presentation and to better understand the courses after LT.
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Inhibition of autotaxin by bile salts and bile salt-like molecules increases its expression by feedback regulation. Biochim Biophys Acta Mol Basis Dis 2021; 1867:166239. [PMID: 34389475 DOI: 10.1016/j.bbadis.2021.166239] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 07/22/2021] [Accepted: 07/31/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Autotaxin is an enzyme that converts lysophospholipid into lysophosphatidic acid (LPA), a highly potent signaling molecule through a range of LPA receptors. It is therefore important to investigate which factors play a role in regulating ATX expression. Since we have reported that ATX levels increase dramatically in patients with various forms of cholestasis, we embarked on a study to reveal factors that influence the enzyme activity ATX as well as its expression level in vitro and in vivo. METHODS Bile from cholestatic patients was fractionated by HPLC and analyzed for modulation of ATX activity. ATX expression was measured in fibroblasts upon stimulation or inhibition of LPA signaling. RESULTS Surprisingly, ATX activity was stimulated by most forms of its product LPA, but it was inhibited by bile salts and bile salt-like molecules, particularly by 3-OH sulfated bile salts and sulfated progesterone metabolites that are known to accumulate during chronic cholestasis and cholestasis of pregnancy, respectively. Activation of fibroblasts by LPA decreased ATX expression by 72%. Conversely, inhibition of LPA signaling increased ATX expression 3-fold, indicating strong feedback regulation by LPA signaling. In fibroblasts, we could verify that inhibition of ATX activity by bile salts induces its expression. Furthermore, induction of cholestasis in mice causes increased plasma ATX activity. CONCLUSIONS Multiple biliary compounds that accumulate in the systemic circulation during cholestasis inhibit ATX activity and thereby increase ATX expression through feedback regulation. This mechanism may contribute to increased serum ATX activity in patients with cholestasis.
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Epidemiology and burden of progressive familial intrahepatic cholestasis: a systematic review. Orphanet J Rare Dis 2021; 16:255. [PMID: 34082807 PMCID: PMC8173883 DOI: 10.1186/s13023-021-01884-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/21/2021] [Indexed: 02/08/2023] Open
Abstract
Background Progressive familial intrahepatic cholestasis is a rare, heterogeneous group of liver disorders of autosomal recessive inheritance, characterised by an early onset of cholestasis with pruritus and malabsorption, which rapidly progresses, eventually culminating in liver failure. For children and their parents, PFIC is an extremely distressing disease. Significant pruritus can lead to severe cutaneous mutilation and may affect many activities of daily living through loss of sleep, irritability, poor attention, and impaired school performance. Methods Databases including MEDLINE and Embase were searched for publications on PFIC prevalence, incidence or natural history, and the economic burden or health-related quality of life of patients with PFIC. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Results Three systematic reviews and twenty-two studies were eligible for inclusion for the epidemiology of PFIC including a total of 2603 patients. Study periods ranged from 3 to 33 years. Local population prevalence of PFIC was reported in three studies, ranging from 9.0 to 12.0% of children admitted with cholestasis, acute liver failure, or splenomegaly. The most detailed data come from the NAPPED study where native liver survival of >15 years is predicted in PFIC2 patients with a serum bile acid concentration below 102 µmol/L following bile diversion surgery. Burden of disease was mainly reported through health-related quality of life (HRQL), rates of surgery and survival. Rates of biliary diversion and liver transplant varied widely depending on study period, sample size and PFIC type, with many patients have multiple surgeries and progressing to liver transplant. This renders data unsuitable for comparison. Conclusion Using robust and transparent methods, this systematic review summarises our current knowledge of PFIC. The epidemiological overview is highly mixed and dependent on presentation and PFIC subtype. Only two studies reported HRQL and mortality results were variable across different subtypes. Lack of data and extensive heterogeneity severely limit understanding across this disease area, particularly variation around and within subtypes. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01884-4.
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Progressive Familial Intrahepatic Cholestasis: Is It Time to Transition to Genetic Cholestasis? J Pediatr Gastroenterol Nutr 2021; 72:641-643. [PMID: 33661247 DOI: 10.1097/mpg.0000000000003111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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11
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Jee A, Sernoskie SC, Uetrecht J. Idiosyncratic Drug-Induced Liver Injury: Mechanistic and Clinical Challenges. Int J Mol Sci 2021; 22:ijms22062954. [PMID: 33799477 PMCID: PMC7998339 DOI: 10.3390/ijms22062954] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/08/2021] [Accepted: 03/11/2021] [Indexed: 02/08/2023] Open
Abstract
Idiosyncratic drug-induced liver injury (IDILI) remains a significant problem for patients and drug development. The idiosyncratic nature of IDILI makes mechanistic studies difficult, and little is known of its pathogenesis for certain. Circumstantial evidence suggests that most, but not all, IDILI is caused by reactive metabolites of drugs that are bioactivated by cytochromes P450 and other enzymes in the liver. Additionally, there is overwhelming evidence that most IDILI is mediated by the adaptive immune system; one example being the association of IDILI caused by specific drugs with specific human leukocyte antigen (HLA) haplotypes, and this may in part explain the idiosyncratic nature of these reactions. The T cell receptor repertoire likely also contributes to the idiosyncratic nature. Although most of the liver injury is likely mediated by the adaptive immune system, specifically cytotoxic CD8+ T cells, adaptive immune activation first requires an innate immune response to activate antigen presenting cells and produce cytokines required for T cell proliferation. This innate response is likely caused by either a reactive metabolite or some form of cell stress that is clinically silent but not idiosyncratic. If this is true it would make it possible to study the early steps in the immune response that in some patients can lead to IDILI. Other hypotheses have been proposed, such as mitochondrial injury, inhibition of the bile salt export pump, unfolded protein response, and oxidative stress although, in most cases, it is likely that they are also involved in the initiation of an immune response rather than representing a completely separate mechanism. Using the clinical manifestations of liver injury from a number of examples of IDILI-associated drugs, this review aims to summarize and illustrate these mechanistic hypotheses.
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Affiliation(s)
- Alison Jee
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON M5S 1A8, Canada;
| | | | - Jack Uetrecht
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON M5S 1A8, Canada;
- Department of Pharmaceutical Sciences, University of Toronto, Toronto, ON M5S 3M2, Canada;
- Correspondence:
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12
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Villanueva-Paz M, Morán L, López-Alcántara N, Freixo C, Andrade RJ, Lucena MI, Cubero FJ. Oxidative Stress in Drug-Induced Liver Injury (DILI): From Mechanisms to Biomarkers for Use in Clinical Practice. Antioxidants (Basel) 2021; 10:390. [PMID: 33807700 PMCID: PMC8000729 DOI: 10.3390/antiox10030390] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/02/2021] [Indexed: 12/11/2022] Open
Abstract
Idiosyncratic drug-induced liver injury (DILI) is a type of hepatic injury caused by an uncommon drug adverse reaction that can develop to conditions spanning from asymptomatic liver laboratory abnormalities to acute liver failure (ALF) and death. The cellular and molecular mechanisms involved in DILI are poorly understood. Hepatocyte damage can be caused by the metabolic activation of chemically active intermediate metabolites that covalently bind to macromolecules (e.g., proteins, DNA), forming protein adducts-neoantigens-that lead to the generation of oxidative stress, mitochondrial dysfunction, and endoplasmic reticulum (ER) stress, which can eventually lead to cell death. In parallel, damage-associated molecular patterns (DAMPs) stimulate the immune response, whereby inflammasomes play a pivotal role, and neoantigen presentation on specific human leukocyte antigen (HLA) molecules trigger the adaptive immune response. A wide array of antioxidant mechanisms exists to counterbalance the effect of oxidants, including glutathione (GSH), superoxide dismutase (SOD), catalase, and glutathione peroxidase (GPX), which are pivotal in detoxification. These get compromised during DILI, triggering an imbalance between oxidants and antioxidants defense systems, generating oxidative stress. As a result of exacerbated oxidative stress, several danger signals, including mitochondrial damage, cell death, and inflammatory markers, and microRNAs (miRNAs) related to extracellular vesicles (EVs) have already been reported as mechanistic biomarkers. Here, the status quo and the future directions in DILI are thoroughly discussed, with a special focus on the role of oxidative stress and the development of new biomarkers.
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Affiliation(s)
- Marina Villanueva-Paz
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, 29071 Málaga, Spain; (M.V.-P.); (M.I.L.)
| | - Laura Morán
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, 28040 Madrid, Spain; (L.M.); (N.L.-A.)
- Health Research Institute Gregorio Marañón (IiSGM), 28009 Madrid, Spain
| | - Nuria López-Alcántara
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, 28040 Madrid, Spain; (L.M.); (N.L.-A.)
| | - Cristiana Freixo
- CINTESIS, Center for Health Technology and Services Research, do Porto University School of Medicine, 4200-319 Porto, Portugal;
| | - Raúl J. Andrade
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, 29071 Málaga, Spain; (M.V.-P.); (M.I.L.)
| | - M Isabel Lucena
- Unidad de Gestión Clínica de Gastroenterología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, 29071 Málaga, Spain; (M.V.-P.); (M.I.L.)
| | - Francisco Javier Cubero
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, 28040 Madrid, Spain; (L.M.); (N.L.-A.)
- 12 de Octubre Health Research Institute (imas12), 28041 Madrid, Spain
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13
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Abstract
Progressive familial intrahepatic cholestasis (PFIC) and Alagille syndrome (AS) are conditions caused by either an autosomal recessive or an autosomal dominant genetic defect, and they are both characterized by cholestasis, jaundice, and severe debilitating pruritus refractory to medical management. Before the advent of liver transplantation, most PFIC patients would die from end-stage liver disease in the first decade of life. Although liver transplantation has led to patients' survival, disease recurrence (PFIC-2) and severe extra-hepatic manifestations of the disease (PFIC-1) occurred post transplant. In the late 1980s, Whitington described the use of partial external biliary diversion in PFIC and AS patients as a successful way to improve symptoms and decrease circulating bile acid serum concentrations. Since then, other diversion techniques have been described (ileal exclusion and partial internal biliary diversion). These techniques have the benefit of avoiding a stoma, but equivalent results have not been demonstrated (recurrence of cholestasis after ileal exclusion, limited follow up after internal biliary diversion). Overall, studies have showed that biliary diversions in children with cholestasis are safe procedures with low morbidity and mortality, and that they can reduce inflammation and ongoing liver injury, therefore delaying or avoiding the need for liver transplantation in some patients.
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14
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Van Vaisberg V, Tannuri ACA, Lima FR, Tannuri U. Ileal exclusion for pruritus treatment in children with progressive familial intrahepatic cholestasis and other cholestatic diseases. J Pediatr Surg 2020; 55:1385-1391. [PMID: 31708211 DOI: 10.1016/j.jpedsurg.2019.09.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 09/02/2019] [Accepted: 09/07/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pruritus is a major health-related quality-of-life burden in progressive familial intrahepatic cholestasis (PFIC) and other childhood cholestatic liver diseases. Several nontransplant surgical techniques were developed in an attempt to ameliorate symptoms and slow disease progression. Very few case-series have been published on a particular intervention, ileal exclusion (IE), which has been considered to be inferior to the other approaches. METHODS We conducted a single-center retrospective chart-review case-series of patients submitted to IE as the first-line surgical treatment at our institution from 1995 to 2018. The primary goal was pruritus relief, followed by survival with the native liver and improvement in biochemical parameters. RESULTS Eleven patients were submitted to IE, with a mean follow-up of 60 months. Complete resolution or significant reduction of pruritus was obtained in 72.7% (n = 8) of patients. One patient (9.1%) had a major postoperative complication that required surgery. No other morbidities were reported. Two cases progressed to end-stage liver disease (ESLD) within the short-term and one year after surgery. CONCLUSIONS This case series study shows that IE provided excellent results in pruritus control and permitted survival with the native liver. We believe IE is a safe procedure, with few associated morbidities, and should be considered more often as primary surgical treatment for PFIC and other cholestasis. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Victor Van Vaisberg
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ana Cristina Aoun Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Fabiana Roberto Lima
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil.
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15
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van Wessel DBE, Thompson RJ, Gonzales E, Jankowska I, Sokal E, Grammatikopoulos T, Kadaristiana A, Jacquemin E, Spraul A, Lipiński P, Czubkowski P, Rock N, Shagrani M, Broering D, Algoufi T, Mazhar N, Nicastro E, Kelly DA, Nebbia G, Arnell H, Björn Fischler, Hulscher JBF, Serranti D, Arikan C, Polat E, Debray D, Lacaille F, Goncalves C, Hierro L, Muñoz Bartolo G, Mozer-Glassberg Y, Azaz A, Brecelj J, Dezsőfi A, Calvo PL, Grabhorn E, Sturm E, van der Woerd WJ, Kamath BM, Wang JS, Li L, Durmaz Ö, Onal Z, Bunt TMG, Hansen BE, Verkade HJ. Genotype correlates with the natural history of severe bile salt export pump deficiency. J Hepatol 2020; 73:84-93. [PMID: 32087350 DOI: 10.1016/j.jhep.2020.02.007] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Mutations in ABCB11 can cause deficiency of the bile salt export pump (BSEP), leading to cholestasis and end-stage liver disease. Owing to the rarity of the disease, the associations between genotype and natural history, or outcomes following surgical biliary diversion (SBD), remain elusive. We aimed to determine these associations by assembling the largest genetically defined cohort of patients with severe BSEP deficiency to date. METHODS This multicentre, retrospective cohort study included 264 patients with homozygous or compound heterozygous pathological ABCB11 mutations. Patients were categorized according to genotypic severity (BSEP1, BSEP2, BSEP3). The predicted residual BSEP transport function decreased with each category. RESULTS Genotype severity was strongly associated with native liver survival (NLS, BSEP1 median 20.4 years; BSEP2, 7.0 years; BSEP3, 3.5 years; p <0.001). At 15 years of age, the proportion of patients with hepatocellular carcinoma was 4% in BSEP1, 7% in BSEP2 and 34% in BSEP3 (p = 0.001). SBD was associated with significantly increased NLS (hazard ratio 0.50; 95% CI 0.27-0.94: p = 0.03) in BSEP1 and BSEP2. A serum bile acid concentration below 102 μmol/L or a decrease of at least 75%, each shortly after SBD, reliably predicted NLS of ≥15 years following SBD (each p <0.001). CONCLUSIONS The genotype of severe BSEP deficiency strongly predicts long-term NLS, the risk of developing hepatocellular carcinoma, and the chance that SBD will increase NLS. Serum bile acid parameters shortly after SBD can predict long-term NLS. LAY SUMMARY This study presents data from the largest genetically defined cohort of patients with severe bile salt export pump deficiency to date. The genotype of patients with severe bile salt export pump deficiency is associated with clinical outcomes and the success of therapeutic interventions. Therefore, genotypic data should be used to guide personalized clinical care throughout childhood and adulthood in patients with this disease.
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Affiliation(s)
- Daan B E van Wessel
- Pediatric Gastroenterology and Hepatology, University Medical Centre Groningen, University of Groningen, The Netherlands
| | | | - Emmanuel Gonzales
- Service d'Hépatologie et de Transplantation Hépatique Pédiatriques, Bicêtre Hôspital, AP-HP, Université Paris-Sud, Paris Saclay, Inserm UMR-S 1174, France; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Irena Jankowska
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER); Gastroenterology, Hepatology, Nutritional Disorders and Paediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Etienne Sokal
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER); Université; Catholique de Louvain, Cliniques St Luc, Brussels, Belgium
| | | | | | - Emmanuel Jacquemin
- Service d'Hépatologie et de Transplantation Hépatique Pédiatriques, Bicêtre Hôspital, AP-HP, Université Paris-Sud, Paris Saclay, Inserm UMR-S 1174, France
| | - Anne Spraul
- Service de Biochemie, Bicêtre Hôspital, AP-HP, Université Paris-Sud, Paris Saclay, Inserm UMR-S 1174, France
| | - Patryk Lipiński
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER); Gastroenterology, Hepatology, Nutritional Disorders and Paediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Piotr Czubkowski
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER); Gastroenterology, Hepatology, Nutritional Disorders and Paediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Nathalie Rock
- Université; Catholique de Louvain, Cliniques St Luc, Brussels, Belgium
| | - Mohammad Shagrani
- Liver & SB Transplant & Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia; Alfaisal University, College of Medicine, Riyadh, Saudi Arabia
| | - Dieter Broering
- Liver & SB Transplant & Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Talal Algoufi
- Liver & SB Transplant & Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Nejat Mazhar
- Liver & SB Transplant & Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Emanuele Nicastro
- Pediatric Hepatology, Gastroenterology and Transplantation, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Deirdre A Kelly
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER); Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Gabriella Nebbia
- Servizio Di Epatologia e Nutrizione Pediatrica, Fondazione Irccs Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Henrik Arnell
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER); Pediatric Digestive Diseases, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Björn Fischler
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER); Pediatric Digestive Diseases, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jan B F Hulscher
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER); Paediatric Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Daniele Serranti
- Paediatric and Liver Unit, Meyer Children's University Hospital of Florence
| | - Cigdem Arikan
- Koc University School of Medicine, Paediatric GI and Hepatology Liver Transplantation Centre, Kuttam System in Liver Medicine, Istanbul, Turkey
| | - Esra Polat
- Hospital Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Dominique Debray
- Unité; d'hépatologie Pédiatrique et Transplantation, Hôpital Necker, Paris, France
| | - Florence Lacaille
- Unité; d'hépatologie Pédiatrique et Transplantation, Hôpital Necker, Paris, France
| | - Cristina Goncalves
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER); Coimbra University Hospital Center, Coimbra, Portugal
| | - Loreto Hierro
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER); Pediatric Liver Service, La Paz University Hospital, Madrid, Spain
| | - Gema Muñoz Bartolo
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER); Pediatric Liver Service, La Paz University Hospital, Madrid, Spain
| | - Yael Mozer-Glassberg
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Centre of Israel
| | - Amer Azaz
- Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Jernej Brecelj
- Department of Gastroenterology, Hepatology and Nutrition, University Children's Hospital Ljubljana, and Department of Paediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Antal Dezsőfi
- 1st Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Pier Luigi Calvo
- Pediatic Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliera Città Della Salute e Della Scienza University Hospital, Torino, Italy
| | - Enke Grabhorn
- Klinik Für Kinder- Und Jugendmedizin, Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany
| | - Ekkehard Sturm
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER); University Children's Hospital Tübingen, Tübingen, Germany
| | - Wendy J van der Woerd
- Wilhelmina Children's Hospital, University Medical Centre Utrecht, Paediatric Gastroenterology, Hepatology and Nutrition, Utrecht, The Netherlands
| | - Binita M Kamath
- The Hospital for Sick Children and the University of Toronto, Toronto, Canada
| | - Jian-She Wang
- Children's Hospital of Fudan University, Shanghai, China
| | - Liting Li
- Children's Hospital of Fudan University, Shanghai, China
| | - Özlem Durmaz
- Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Zerrin Onal
- Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Ton M G Bunt
- Pediatric Gastroenterology and Hepatology, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, University Health Network, Canada; IHPME, University of Toronto, Canada
| | - Henkjan J Verkade
- Pediatric Gastroenterology and Hepatology, University Medical Centre Groningen, University of Groningen, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER).
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Uetrecht J. Mechanistic Studies of Idiosyncratic DILI: Clinical Implications. Front Pharmacol 2019; 10:837. [PMID: 31402866 PMCID: PMC6676790 DOI: 10.3389/fphar.2019.00837] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/01/2019] [Indexed: 12/18/2022] Open
Abstract
The idiosyncratic nature of idiosyncratic drug-induced liver injury (IDILI) makes mechanistic studies very difficult, and little is known with certainty. However, the fact that the IDILI caused by some drugs is associated with specific HLA genotypes provides strong evidence that it is mediated by the adaptive immune system. This is also consistent with the histology and the general characteristics of IDILI. However, there are other mechanistic hypotheses. Various in vitro and in vivo systems have been used to test hypotheses. Two other hypotheses are mitochondrial injury and inhibition of the bile salt export pump. It is possible that these mechanisms are responsible for some cases of IDILI or that these mechanisms are complementary and are involved in initiating an immune response. In general, it is believed that the initiation of an immune response requires activation of antigen-presenting cells by molecules such as danger-associated molecular pattern molecules (DAMPs). An attractive hypothesis for the mechanism by which DAMPs induce an immune response is through the activation of inflammasomes. The dominant immune response in the liver is immune tolerance, and it is only when immune tolerance fails that significant liver injury occurs. Consistent with this concept, an animal model was developed in which immune checkpoint inhibition unmasked the ability of drugs to cause liver injury. Although it appears that the liver damage is mediated by the adaptive immune system, an innate immune response is required for an adaptive immune response. The innate immune response is not dependent on specific HLA genes or T cell receptors and may occur in most patients and animals treated with a drug that can cause IDILI. Studies of the subclinical innate immune response to drugs may provide important mechanistic clues and provide a method to screen drugs for their potential to cause IDILI.
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Affiliation(s)
- Jack Uetrecht
- Department of Pharmaceutical Sciences, University of Toronto, Toronto, ON, Canada
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17
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Baker A, Kerkar N, Todorova L, Kamath BM, Houwen RHJ. Systematic review of progressive familial intrahepatic cholestasis. Clin Res Hepatol Gastroenterol 2019; 43:20-36. [PMID: 30236549 DOI: 10.1016/j.clinre.2018.07.010] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 06/29/2018] [Accepted: 07/23/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Progressive familial intrahepatic cholestasis (PFIC) is a heterogeneous group of rare genetic disorders associated with bile acid secretion or transport defects. This is the first systematic review of the epidemiology, natural history and burden of PFIC. METHODS MEDLINE and Embase were searched for publications on PFIC prevalence, incidence or natural history, and the economic burden or health-related quality of life (HRQoL) of patients with PFIC. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. RESULTS Of 1269 records screened, 20 were eligible (epidemiology, 17; humanistic burden, 5; both, 2). Incidence of intrahepatic cholestasis, including but not limited to PFIC, was 1/18 000 live births in one study that did not use genetic testing. In two studies of infants and children (2-18 years) with cholestasis, 12-13% had genetically diagnosed PFIC. Of the three main PFIC subtypes, PFIC2 was the most common (21-91% of patients). Common symptoms (e.g. pruritus, jaundice, hepatomegaly, splenomegaly) generally appeared at about 3 months of age and tended to emerge earliest in patients with PFIC2. Patients reported that pruritus was often severe and led to dermal damage and reduced HRQoL. Disease progression led to complications including liver failure and hepatocellular carcinoma, with 20-83% of patients requiring liver transplantation. Mortality was 0-87% across 10 studies (treatment varied among studies), with a median age at death of ~4 years in one study. CONCLUSIONS Patients with PFIC face debilitating symptoms and poor prognosis. Further research is needed to inform patient management and clinical trial design. Published data on the epidemiology and socioeconomic burden of PFIC is limited.
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Affiliation(s)
- Alastair Baker
- Paediatric Liver Centre, King's College Hospital, London, UK
| | - Nanda Kerkar
- Division of Gastroenterology, Hepatology and Nutrition, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Roderick H J Houwen
- Pediatric Gastroenterology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands.
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18
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Chen L, Xiao H, Ren XH, Li L. Long-term outcomes after cholecystocolostomy for progressive familial intrahepatic cholestasis. Hepatol Res 2018; 48:1163-1171. [PMID: 29934967 DOI: 10.1111/hepr.13222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/26/2018] [Accepted: 06/13/2018] [Indexed: 12/12/2022]
Abstract
AIM To evaluate the long-term efficacy of cholecystocolostomy surgery for progressive familial intrahepatic cholestasis (PFIC). METHODS From August 2003 to November 2014, 34 clinically diagnosed children, including 11 with familial intrahepatic cholestasis-1 (FIC1), 13 with bile salt export pump (BSEP) disease, five with low γ-glutamyl transpeptidase (GGT) disease (levels <100 U/L), and five with multidrug resistance class III (MDR3) disease with high GGT (>100 U/L), were identified in our center. Data were collected retrospectively from individuals who collectively had 36 surgical operations and two orthotopic liver transplantations (OLT). RESULTS Serum total bilirubin (0 = 163.54 ± 106.02, 36 months = 23.38 ± 17.66 μmol/L) and bile acid (0 = 325.83 ± 153.09, 36 months = 48.36 ± 79.71 μmol/L) decreased after cholecystocolostomy in PFIC patients (P < 0.001). All patients experienced decreased severity of pruritus (88.2% vs. 16.1%, P < 0.001) and a greater freedom from growth retardation after cholecystocolostomy (-3.35 vs. -1.03, P < 0.001). Defecation frequency increased in PFIC patients after cholecystocolostomy (P = 0.002). Four patients (three with FIC1 and one with BSEP) experienced recurrence of cholestasis and two underwent reoperation. Two BSEP patients underwent OLT. One patient with BSEP and one patient with MDR3 died due to severe diarrhea and dehydration; one BSEP patient died of intractable constipation. CONCLUSIONS This is the first long-term, large-scale analysis of cholecystocolostomy approaches for PFIC. Approaches single and well tolerated, and generally result in improvement of pruritus and cholestasis.
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Affiliation(s)
- Long Chen
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Hui Xiao
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiang-Hai Ren
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Long Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, China
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Kenna JG, Uetrecht J. Do In Vitro Assays Predict Drug Candidate Idiosyncratic Drug-Induced Liver Injury Risk? Drug Metab Dispos 2018; 46:1658-1669. [PMID: 30021844 DOI: 10.1124/dmd.118.082719] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/05/2018] [Indexed: 12/16/2022] Open
Abstract
In vitro assays are commonly used during drug discovery to try to decrease the risk of idiosyncratic drug-induced liver injury (iDILI). But how effective are they at predicting risk? One of the most widely used methods evaluates cell cytotoxicity. Cytotoxicity assays that used cell lines that are very different from normal hepatocytes, and high concentrations of drug, were not very accurate at predicting idiosyncratic drug reaction risk. Even cytotoxicity assays that use more biologically normal cells resulted in many false-positive and false-negative results. Assays that quantify reactive metabolite formation, mitochondrial injury, and bile salt export pump (BSEP) inhibition have also been described. Although evidence suggests that reactive metabolite formation and BSEP inhibition can play a role in the mechanism of iDILI, these assays are not very accurate at predicting risk. In contrast, inhibition of the mitochondrial electron transport chain appears not to play an important role in the mechanism of iDILI, although other types of mitochondrial injury may do so. It is likely that there are many additional mechanisms by which drugs can cause iDILI. However, simply measuring more parameters is unlikely to provide better predictive assays unless those parameters are actually involved in the mechanism of iDILI. Hence, a better mechanistic understanding of iDILI is required; however, mechanistic studies of iDILI are very difficult. There is substantive evidence that most iDILI is immune mediated; therefore, the most accurate assays may involve those that determine immune responses to drugs. New methods to manipulate immune tolerance may greatly facilitate development of more suitable methods.
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Affiliation(s)
- J Gerry Kenna
- Safer Medicines Trust, Kingsbridge, United Kingdom (J.G.K.); and Faculties of Pharmacy and Medicine, University of Toronto, Toronto, Ontario, Canada (J.U.)
| | - Jack Uetrecht
- Safer Medicines Trust, Kingsbridge, United Kingdom (J.G.K.); and Faculties of Pharmacy and Medicine, University of Toronto, Toronto, Ontario, Canada (J.U.)
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Erginel B, Soysal FG, Durmaz O, Celik A, Salman T. Long-term outcomes of six patients after partial internal biliary diversion for progressive familial intrahepatic cholestasis. J Pediatr Surg 2018; 53:468-471. [PMID: 29174177 DOI: 10.1016/j.jpedsurg.2017.10.055] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 10/19/2017] [Accepted: 10/22/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Partial internal biliary diversion (PIBD) is an alternative approach for the treatment of devastating pruritus in patients with progressive familial intrahepatic cholestasis (PFIC). In these patients quality of life can be improved and progression of liver disease can be delayed while waiting for liver transplantation. The aim of our study was to evaluate six patients with PFIC who have undergone PIBD in long-term follow-up. METHODS Retrospective review of the records of six patients who underwent PIBD for PFIC between 2008 and 2010 was conducted to evaluate age, growth, clinical and laboratory studies for long-term outcome. RESULTS Serum postoperative bile acid levels were reduced from a mean 340.1μmol/L (range 851-105) preoperatively to a mean of 96.3μmol/L at postoperative fifth year. The difference between pre- and postoperative bile acid levels was statistically significant (p=0.018). AST decreased from 79.1U/L (range 43-150U/L) to 64.6U/L (range 18-172U/L), ALT decreased from 102.8U/L (range 35-270U/L) to 84.6U/L and total bilirubin decreased from 2.9μmol/L (range 0.35-6.4μmol/L) to 1.53μmol/L (range 0.3-2.4). Again, the decrease in total bilirubin levels was significant (p=0.043). Pruritus was diminished from a mean of +4 (range 4-4) preoperatively to a mean of +2 (4-0). One patient who underwent liver transplantation owing to relapsing pruritus died from postoperative sepsis in the early postoperative period at the fifth year after PBID. Five symptom-free patients have not required liver transplantation at a mean period of 6.1±0.83years (5.1-7.0years) follow-up. CONCLUSION PBID is an effective surgical procedure in the long-term and can delay the need for liver transplantation in children with PFIC by reducing jaundice and pruritus.
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Affiliation(s)
- Basak Erginel
- Istanbul University, Istanbul Medical Faculty, Department of Pediatric Surgery.
| | - Feryal Gun Soysal
- Istanbul University, Istanbul Medical Faculty, Department of Pediatric Surgery
| | - Ozlem Durmaz
- Istanbul University, Istanbul Medical Faculty, Department of Pediatric Gastroenterology
| | - Alaattin Celik
- Istanbul University, Istanbul Medical Faculty, Department of Pediatric Surgery
| | - Tansu Salman
- Istanbul University, Istanbul Medical Faculty, Department of Pediatric Surgery
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Abdelrhim H, Khan S, Heaton P, Peeka R. Balancing Medical and Non-Accidental Causes of Multiple Fractures in a Child with Progressive Familial Intrahepatic Cholestasis. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:1190-1193. [PMID: 29118315 PMCID: PMC5691591 DOI: 10.12659/ajcr.905807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patient: Female, 2 Final Diagnosis: Hepatic rickets Symptoms: Pain Medication: — Clinical Procedure: Skeletal survey Specialty: Pediatrics and Neonatology
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Affiliation(s)
- Hisham Abdelrhim
- Department of Paediatrics, Royal Glamorgan Hospital, Cwm Taf University Health Board, Llantrisant, Rhondda Cynon Taf, United Kingdom
| | - Sami Khan
- Department of Paediatrics, Royal Glamorgan Hospital, Cwm Taf University Health Board, Llantrisant, Rhondda Cynon Taf, United Kingdom
| | - Paul Heaton
- Department of Paediatrics, Yeovil District Hospital, Yeovil, Somerset, United Kingdom
| | - Rajeev Peeka
- Department of Paediatrics, Royal Glamorgan Hospital, Cwm Taf University Health Board, Llantrisant, Rhondda Cynon Taf, United Kingdom
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22
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Zhang Y, Jackson JP, St Claire RL, Freeman K, Brouwer KR, Edwards JE. Obeticholic acid, a selective farnesoid X receptor agonist, regulates bile acid homeostasis in sandwich-cultured human hepatocytes. Pharmacol Res Perspect 2017; 5. [PMID: 28805978 PMCID: PMC5684861 DOI: 10.1002/prp2.329] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/10/2017] [Indexed: 12/11/2022] Open
Abstract
Farnesoid X receptor (FXR) is a master regulator of bile acid homeostasis through transcriptional regulation of genes involved in bile acid synthesis and cellular membrane transport. Impairment of bile acid efflux due to cholangiopathies results in chronic cholestasis leading to abnormal elevation of intrahepatic and systemic bile acid levels. Obeticholic acid (OCA) is a potent and selective FXR agonist that is 100‐fold more potent than the endogenous ligand chenodeoxycholic acid (CDCA). The effects of OCA on genes involved in bile acid homeostasis were investigated using sandwich‐cultured human hepatocytes. Gene expression was determined by measuring mRNA levels. OCA dose‐dependently increased fibroblast growth factor‐19 (FGF‐19) and small heterodimer partner (SHP) which, in turn, suppress mRNA levels of cholesterol 7‐alpha‐hydroxylase (CYP7A1), the rate‐limiting enzyme for de novo synthesis of bile acids. Consistent with CYP7A1 suppression, total bile acid content was decreased by OCA (1 μmol/L) to 42.7 ± 20.5% relative to control. In addition to suppressing de novo bile acids synthesis, OCA significantly increased the mRNA levels of transporters involved in bile acid homeostasis. The bile salt excretory pump (BSEP), a canalicular efflux transporter, increased by 6.4 ± 0.8‐fold, and the basolateral efflux heterodimer transporters, organic solute transporter α (OSTα) and OSTβ increased by 6.4 ± 0.2‐fold and 42.9 ± 7.9‐fold, respectively. The upregulation of BSEP and OSTα and OSTβ, by OCA reduced the intracellular concentrations of d8‐TCA, a model bile acid, to 39.6 ± 8.9% relative to control. These data demonstrate that OCA does suppress bile acid synthesis and reduce hepatocellular bile acid levels, supporting the use of OCA to treat bile acid‐induced toxicity observed in cholestatic diseases.
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Lee SJ, Kim JE, Choe BH, Seo AN, Bae HI, Hwang SK. Early Diagnosis of ABCB11 Spectrum Liver Disorders by Next Generation Sequencing. Pediatr Gastroenterol Hepatol Nutr 2017; 20:114-123. [PMID: 28730136 PMCID: PMC5517378 DOI: 10.5223/pghn.2017.20.2.114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/21/2016] [Indexed: 01/27/2023] Open
Abstract
PURPOSE The goal of this study was the early diagnosis of ABCB11 spectrum liver disorders, especially those focused on benign recurrent intrahepatic cholestasis and progressive familial intrahepatic cholestasis. METHODS Fifty patients presenting neonatal cholestasis were evaluated to identify underlying etiologies. Genetic analysis was performed on patients suspected to have syndromic diseases or ABCB11 spectrum liver disorders. Two families with proven ABCB11 spectrum liver disorders were subjected to genetic analyses to confirm the diagnosis and were provided genetic counseling. Whole exome sequencing and Sanger sequencing were performed on the patients and the family members. RESULTS Idiopathic or viral hepatitis was diagnosed in 34%, metabolic disease in 20%, total parenteral nutrition induced cholestasis in 16%, extrahepatic biliary atresia in 14%, genetic disease in 10%, neonatal lupus in 2%, congenital syphilis in 2%, and choledochal cyst in 2% of the patients. The patient with progressive familial intrahepatic cholestasis had novel heterozygous mutations of ABCB11 c.11C>G (p.Ser4*) and c.1543A>G (p.Asn515Asp). The patient with benign recurrent intrahepatic cholestasis had homozygous mutations of ABCB11 c.1331T>C (p.Val444Ala) and heterozygous, c.3084A>G (p.Ala1028Ala). Genetic confirmation of ABCB11 spectrum liver disorder led to early liver transplantation in the progressive familial intrahepatic cholestasis patient. In addition, the atypically severe benign recurrent intrahepatic cholestasis patient was able to avoid unnecessary liver transplantation after genetic analysis. CONCLUSION ABCB11 spectrum liver disorders can be clinically indistinguishable as they share similar characteristics related to acute episodes. A comprehensive genetic analysis will facilitate optimal diagnosis and treatment.
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Affiliation(s)
- Su Jeong Lee
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jung Eun Kim
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Byung-Ho Choe
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - An Na Seo
- Department of Pathology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Han-Ik Bae
- Department of Pathology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Su-Kyeong Hwang
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
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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: 2.0] [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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25
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Wang KS, Tiao G, Bass LM, Hertel PM, Mogul D, Kerkar N, Clifton M, Azen C, Bull L, Rosenthal P, Stewart D, Superina R, Arnon R, Bozic M, Brandt ML, Dillon PA, Fecteau A, Iyer K, Kamath B, Karpen S, Karrer F, Loomes KM, Mack C, Mattei P, Miethke A, Soltys K, Turmelle YP, West K, Zagory J, Goodhue C, Shneider BL. Analysis of surgical interruption of the enterohepatic circulation as a treatment for pediatric cholestasis. Hepatology 2017; 65:1645-1654. [PMID: 28027587 PMCID: PMC5397365 DOI: 10.1002/hep.29019] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 11/21/2016] [Accepted: 12/20/2016] [Indexed: 12/12/2022]
Abstract
UNLABELLED To evaluate the efficacy of nontransplant surgery for pediatric cholestasis, 58 clinically diagnosed children, including 20 with Alagille syndrome (ALGS), 16 with familial intrahepatic cholestasis-1 (FIC1), 18 with bile salt export pump (BSEP) disease, and 4 others with low γ-glutamyl transpeptidase disease (levels <100 U/L), were identified across 14 Childhood Liver Disease Research Network (ChiLDReN) centers. Data were collected retrospectively from individuals who collectively had 39 partial external biliary diversions (PEBDs), 11 ileal exclusions (IEs), and seven gallbladder-to-colon (GBC) diversions. Serum total bilirubin decreased after PEBD in FIC1 (8.1 ± 4.0 vs. 2.9 ± 4.1 mg/dL, preoperatively vs. 12-24 months postoperatively, respectively; P = 0.02), but not in ALGS or BSEP. Total serum cholesterol decreased after PEBD in ALGS patients (695 ± 465 vs. 457 ± 319 mg/dL, preoperatively vs. 12-24 months postoperatively, respectively; P = 0.0001). Alanine aminotransferase levels increased in ALGS after PEBD (182 ± 70 vs. 260 ± 73 IU/L, preoperatively vs. 24 months; P = 0.03), but not in FIC1 or BSEP. ALGS, FIC1, and BSEP patients experienced less severely scored pruritus after PEBD (ALGS, 100% vs. 9% severe; FIC1, 64% vs. 10%; BSEP, 50% vs. 20%, preoperatively vs. >24 months postoperatively, respectively; P < 0.001). ALGS patients experienced a trend toward greater freedom from xanthomata after PEBD. There was a trend toward decreased pruritus in FIC1 after IE and GBC. Vitamin K supplementation increased in ALGS after PEBD (33% vs. 77%; P = 0.03). Overall, there were 15 major complications after surgery. Twelve patients (3 ALGS, 3 FIC1, and 6 BSEP) subsequently underwent liver transplantation. CONCLUSION This was a multicenter analysis of nontransplant surgical approaches to intrahepatic cholestasis. Approaches vary, are well tolerated, and generally, although not uniformly, result in improvement of pruritus and cholestasis. (Hepatology 2017;65:1645-1654).
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Affiliation(s)
| | - Greg Tiao
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Lee M. Bass
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | | | | | - Nanda Kerkar
- Children’s Hospital Los Angeles, Los Angeles, CA
| | | | - Colleen Azen
- Children’s Hospital Los Angeles, Los Angeles, CA
| | - Laura Bull
- University of California, San Francisco, CA
| | | | | | | | | | - Molly Bozic
- Riley Hospital for Children, Indianapolis, IN
| | | | | | | | | | | | - Saul Karpen
- Children’s Healthcare of Atlanta, Atlanta, GA
| | | | | | - Cara Mack
- Children’s Hospital Colorado, Aurora, CO
| | - Peter Mattei
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Kyle Soltys
- Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | | | - Karen West
- Riley Hospital for Children, Indianapolis, IN
| | | | - Cat Goodhue
- Children’s Hospital Los Angeles, Los Angeles, CA
| | - Benjamin L. Shneider
- Texas Children’s Hospital, Houston, TX,Children’s Hospital of Pittsburgh, Pittsburgh, PA
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26
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Clinical Variability After Partial External Biliary Diversion in Familial Intrahepatic Cholestasis 1 Deficiency. J Pediatr Gastroenterol Nutr 2017; 64:425-430. [PMID: 28045770 DOI: 10.1097/mpg.0000000000001493] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Familial intrahepatic cholestasis 1 (FIC1) deficiency is caused by a mutation in the ATP8B1 gene. Partial external biliary diversion (PEBD) is pursued to improve pruritus and arrest disease progression. Our aim is to describe clinical variability after PEBD in FIC1 disease. METHODS We performed a single-center, retrospective review of genetically confirmed FIC1 deficient patients who received PEBD. Clinical outcomes after PEBD were cholestasis, pruritus, fat-soluble vitamin supplementation, growth, and markers of disease progression that included splenomegaly and aspartate aminotransferase-to-platelet ratio index. RESULTS Eight patients with FIC1 disease and PEBD were included. Mean follow-up was 32 months (range 15-65 months). After PEBD, total bilirubin was <2 mg/dL in all patients at 8 months after surgery, but 7 of 8 subsequently experienced a total of 15 recurrent cholestatic events. Subjective assessments of pruritus demonstrated improvement, but itching exacerbation occurred during cholestatic episodes. High-dose fat-soluble vitamin supplementation persisted, with increases needed during cholestatic episodes. Weight z scores improved (-3.4 to -1.65, P < 0.01). Splenomegaly did not worsen or develop and 1 patient developed an aminotransferase-to-platelet ratio index score of >0.7 suggesting development of fibrosis 24 months after PEBD. CONCLUSIONS Clinical variability is evident among genetically defined FIC1 deficient patients after PEBD, even among those with identical mutations. Recurrent, self-limited episodes of cholestasis and pruritus are reminiscent of the benign recurrent intrahepatic cholestasis phenotype. Despite diversion of bile from the intestinal lumen, weight gain improved while fat-soluble vitamin requirements persisted. Significant progression of liver disease was not evident during follow-up.
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27
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Jankowska I, Czubkowski P, Wierzbicka A, Pawłowska J, Kaliciński P, Socha P. Influence of Partial External Biliary Diversion on the Lipid Profile in Children With Progressive Familial Intrahepatic Cholestasis. J Pediatr Gastroenterol Nutr 2016; 63:598-602. [PMID: 27875503 DOI: 10.1097/mpg.0000000000001185] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The concentration of bile acids is highly increased in progressive familial intrahepatic cholestasis (PFIC). Bile acids are the end products of cholesterol metabolism, and aid in the absorption of fat-soluble vitamins and dietary fat. The aim of our study was to investigate lipid metabolism in patients with PFIC with focus on the effect of partial external biliary diversion (PEBD). METHODS In 26 patients with PFIC, who underwent PEBD surgery at the median age of 2.2 years (range: 0.4-16.6), we analyzed the concentrations of lipids and apolipoproteins both before and 6 months after PEBD. Patients were split into 2 groups according to the outcome of surgery (either "good" or "poor"), and were analyzed separately. A "good" result following surgery was defined as complete relief from pruritus, and normalization of total bilirubin (<1.0 mg/dL) and bile acid concentration in serum (<12 μmol/L). RESULTS We found abnormal lipid concentrations at baseline in all 26 patients: cholesterol was increased (>190 mg/dL) in 13 patients, phospholipids were increased (>250 mg/dL) in 5 patients, and triglyceride concentration was increased (>150 mg/dL) in 13 patients. After PEBD, the concentrations of plasma cholesterol, triglycerides, and phospholipids decreased significantly, whereas, ApoA-I and high-density lipoprotein cholesterol concentrations increased and the concentrations of apolipoprotein B, low-density lipoprotein cholesterol, and very low-density lipoprotein cholesterol significantly decreased. PEBD had neither an effect on ApoE concentration nor on lecithin-cholesterol acyl transferase activity. In the group with a "poor" outcome report following PEBD, total serum cholesterol concentration decreased significantly, and no effect on the concentrations of triglycerides and phospholipids were observed. CONCLUSIONS Patients with PFIC present with a high risk of lipid disturbances. PEBD has a beneficial effect on lipid profile in the majority of cases.
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Affiliation(s)
- Irena Jankowska
- *Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics †Department of Biochemistry, Radioimmunology and Experimental Medicine ‡Department of Pediatric Surgery and Organ Transplantation, The Children's Memorial Health Institute, Warsaw, Poland
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28
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Cho T, Uetrecht J. How Reactive Metabolites Induce an Immune Response That Sometimes Leads to an Idiosyncratic Drug Reaction. Chem Res Toxicol 2016; 30:295-314. [DOI: 10.1021/acs.chemrestox.6b00357] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Tiffany Cho
- Faculty
of Pharmacy, University of Toronto, Toronto, Ontario, Canada M5S 3M2
| | - Jack Uetrecht
- Faculty
of Pharmacy, University of Toronto, Toronto, Ontario, Canada M5S 3M2
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29
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van der Mark VA, Ghiboub M, Marsman C, Zhao J, van Dijk R, Hiralall JK, Ho-Mok KS, Castricum Z, de Jonge WJ, Oude Elferink RPJ, Paulusma CC. Phospholipid flippases attenuate LPS-induced TLR4 signaling by mediating endocytic retrieval of Toll-like receptor 4. Cell Mol Life Sci 2016; 74:715-730. [PMID: 27628304 PMCID: PMC5272906 DOI: 10.1007/s00018-016-2360-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 08/31/2016] [Accepted: 09/06/2016] [Indexed: 01/01/2023]
Abstract
P4-ATPases are lipid flippases that catalyze the transport of phospholipids to create membrane phospholipid asymmetry and to initiate the biogenesis of transport vesicles. Here we show, for the first time, that lipid flippases are essential to dampen the inflammatory response and to mediate the endotoxin-induced endocytic retrieval of Toll-like receptor 4 (TLR4) in human macrophages. Depletion of CDC50A, the β-subunit that is crucial for the activity of multiple P4-ATPases, resulted in endotoxin-induced hypersecretion of proinflammatory cytokines, enhanced MAP kinase signaling and constitutive NF-κB activation. In addition, CDC50A-depleted THP-1 macrophages displayed reduced tolerance to endotoxin. Moreover, endotoxin-induced internalization of TLR4 was strongly reduced and coincided with impaired endosomal MyD88-independent signaling. The phenotype of CDC50A-depleted cells was also induced by separate knockdown of two P4-ATPases, namely ATP8B1 and ATP11A. We conclude that lipid flippases are novel elements of the innate immune response that are essential to attenuate the inflammatory response, possibly by mediating endotoxin-induced internalization of TLR4.
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Affiliation(s)
- Vincent A van der Mark
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands
| | - Mohammed Ghiboub
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands
| | - Casper Marsman
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands
| | - Jing Zhao
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands
| | - Remco van Dijk
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands
| | - Johan K Hiralall
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands
| | - Kam S Ho-Mok
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands
| | - Zoë Castricum
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands
| | - Wouter J de Jonge
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands
| | - Ronald P J Oude Elferink
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands
| | - Coen C Paulusma
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands.
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The phospholipid flippase ATP8B1 mediates apical localization of the cystic fibrosis transmembrane regulator. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2016; 1863:2280-8. [PMID: 27301931 DOI: 10.1016/j.bbamcr.2016.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/10/2016] [Indexed: 11/23/2022]
Abstract
Progressive familial intrahepatic cholestasis type 1 (PFIC1) is caused by mutations in the gene encoding the phospholipid flippase ATP8B1. Apart from severe cholestatic liver disease, many PFIC1 patients develop extrahepatic symptoms characteristic of cystic fibrosis (CF), such as pulmonary infection, sweat gland dysfunction and failure to thrive. CF is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR), a chloride channel essential for epithelial fluid transport. Previously it was shown that CFTR transcript levels were strongly reduced in livers of PFIC1 patients. Here we have investigated the hypothesis that ATP8B1 is important for proper CFTR expression and function. We analyzed CFTR expression in ATP8B1-depleted intestinal and pulmonary epithelial cell lines and assessed CFTR function by measuring short-circuit currents across transwell-grown ATP8B1-depleted intestinal T84 cells and by a genetically-encoded fluorescent chloride sensor. In addition, we studied CFTR surface expression upon induction of CFTR transcription. We show that CFTR protein levels are strongly reduced in the apical membrane of human ATP8B1-depleted intestinal and pulmonary epithelial cell lines, a phenotype that coincided with reduced CFTR activity. Apical membrane insertion upon induction of ectopically-expressed CFTR was strongly impaired in ATP8B1-depleted cells. We conclude that ATP8B1 is essential for correct apical localization of CFTR in human intestinal and pulmonary epithelial cells, and that impaired CFTR localization underlies some of the extrahepatic phenotypes observed in ATP8B1 deficiency.
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Abstract
OBJECTIVES Byler disease, originally described in Amish kindred, results from mutations in ATPase Class I Type 8b Member 1 (ATP8b1). Specific clinical reports of Amish Byler disease were last published 40 years ago. These investigations were directed at the present detailed clinical understanding of the early course of hepatic manifestations of Byler disease. METHODS This study analyzed routine clinical practice and outcomes of children with Byler disease (defined by homozygous c.923G>T mutation in ATP8b1), who initially presented to Children's Hospital of Pittsburgh of UPMC between January 2007 and October 2014. Data were analyzed to the earlier of 24 months of age or partial external biliary diversion. RESULTS Six children presented between 1 and 135 days of life: 2 presented with newborn direct hyperbilirubinemia, 2 had complications of coagulopathy, 1 had failure to thrive and rickets, and 1 sibling was identified by newborn genetic testing. Intensive fat-soluble vitamin supplementation was required to prevent insufficiencies in vitamins D, E, and K. Hyperbilirubinemia was variable both over time and between children. Serum bile acid levels were elevated, whereas γ-glutamyltranspeptidase levels were low normal. Scratching behavior (pruritus) was intractable in 4 of 6 children with onset between 6 and 12 months of age. Features of portal hypertension were not observed. Partial external biliary diversion was used during the second year of life in 4 children. CONCLUSIONS Detailed analysis of Byler disease revealed varied disease presentation and course. Nutritional issues and pruritus dominated the clinical picture in the first 2 years of life.
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Total serum bilirubin predicts fat-soluble vitamin deficiency better than serum bile acids in infants with biliary atresia. J Pediatr Gastroenterol Nutr 2014; 59:702-7. [PMID: 25419594 PMCID: PMC4243585 DOI: 10.1097/mpg.0000000000000547] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Fat-soluble vitamin (FSV) deficiency is a well-recognized consequence of cholestatic liver disease and reduced intestinal intraluminal bile acid. We hypothesized that serum bile acid (SBA) would predict biochemical FSV deficiency better than serum total bilirubin (TB) level in infants with biliary atresia. METHODS Infants enrolled in the Trial of Corticosteroid Therapy in Infants with Biliary Atresia after hepatoportoenterostomy were the subjects of this investigation. Infants received standardized FSV supplementation and monitoring of TB, SBA, and vitamin levels at 1, 3, and 6 months. A logistic regression model was used with the binary indicator variable insufficient/sufficient as the outcome variable. Linear and nonparametric correlations were made between specific vitamin measurement levels and either TB or SBA. RESULTS The degree of correlation for any particular vitamin at a specific time point was higher with TB than with SBA (higher for TB in 31 circumstances vs 3 circumstances for SBA). Receiver operating characteristic curve shows that TB performed better than SBA (area under the curve 0.998 vs 0.821). Including both TB and SBA did not perform better than TB alone (area under the curve 0.998). CONCLUSIONS We found that TB was a better predictor of FSV deficiency than SBA in infants with biliary atresia. The role of SBA as a surrogate marker of FSV deficiency in other cholestatic liver diseases, such as progressive familial intrahepatic cholestasis, α-1-antitrypsin deficiency, and Alagille syndrome in which the pathophysiology is dominated by intrahepatic cholestasis, warrants further study.
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Management of neonatal cholestasis: Consensus statement of the pediatric gastroenterology chapter of Indian academy of pediatrics. Indian Pediatr 2014; 51:203-10. [DOI: 10.1007/s13312-014-0375-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Srivastava A. Progressive familial intrahepatic cholestasis. J Clin Exp Hepatol 2014; 4:25-36. [PMID: 25755532 PMCID: PMC4017198 DOI: 10.1016/j.jceh.2013.10.005] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 10/31/2013] [Indexed: 12/12/2022] Open
Abstract
Progressive familial intrahepatic cholestasis (PFIC) is a group of rare disorders which are caused by defect in bile secretion and present with intrahepatic cholestasis, usually in infancy and childhood. These are autosomal recessive in inheritance. The estimated incidence is about 1 per 50,000 to 1 per 100,000 births, although exact prevalence is not known. These diseases affect both the genders equally and have been reported from all geographical areas. Based on clinical presentation, laboratory findings, liver histology and genetic defect, these are broadly divided into three types-PFIC type 1, PFIC type 2 and PFIC type 3. The defect is in ATP8B1 gene encoding the FIC1 protein, ABCB 11 gene encoding BSEP protein and ABCB4 gene encoding MDR3 protein in PFIC1, 2 and 3 respectively. The basic defect is impaired bile salt secretion in PFIC1/2 whereas in PFIC3, it is reduced biliary phospholipid secretion. The main clinical presentation is in the form of cholestatic jaundice and pruritus. Serum gamma glutamyl transpeptidase (GGT) is normal in patients with PFIC1/2 while it is raised in patients with PFIC3. Treatment includes nutritional support (adequate calories, supplementation of fat soluble vitamins and medium chain triglycerides) and use of medications to relieve pruritus as initial therapy followed by biliary diversion procedures in selected patients. Ultimately liver transplantation is needed in most patients as they develop progressive liver fibrosis, cirrhosis and end stage liver disease. Due to the high risk of developing liver tumors in PFIC2 patients, monitoring is recommended from infancy. Mutation targeted pharmacotherapy, gene therapy and hepatocyte transplantation are being explored as future therapeutic options.
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Key Words
- ABC, ATP binding cassette
- ASBT, apical sodium bile salt transporter
- ATP, adenosine triphosphate
- ATPase, adenosine triphosphatase
- BRIC, benign recurrent intrahepatic cholestasis
- BSEP, bile salt exporter protein
- CFTR, cystic fibrosis transmembrane conductance regulator
- CYP, cytochrome P
- DNA, deoxyribonucleic acid
- ERAD, endoplasmic reticulum associated degradation
- ESLD, end stage liver disease
- FIC1, familial intrahepatic cholestasis protein 1
- FXR, farnesoid X receptor
- HCC, hepatocellular carcinoma
- IB, ileal bypass
- ICP, intrahepatic cholestasis of pregnancy
- LT, liver transplant
- MARS, Molecular Adsorbent Recirculating System
- MDR, multidrug resistance protein
- MRCP, magnetic resonance cholangiopancreaticography
- PBD, partial biliary drainage
- PEBD, partial external biliary drainage
- PFIC, progressive familial intrahepatic cholestasis
- PIBD, partial internal biliary drainage
- PPAR, peroxisome proliferator activator receptor
- UDCA, ursodeoxycholic acid
- bile secretion
- children
- cholestasis
- familial
- mRNA, messenger ribonucleic acid
- pGp, p-glycoprotein
- pruritus
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Affiliation(s)
- Anshu Srivastava
- Address for correspondence: Anshu Srivastava, Associate Professor, Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh 226014, India. Tel.: +91 522 2495212, +91 9935219497 (mobile); fax: +91 522 2668017.
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Abstract
OBJECTIVES Children with progressive familial intrahepatic cholestasis (PFIC) rarely benefit from medical treatment and most patients require surgical intervention. Partial external biliary diversion (PEBD) is presently the treatment of choice but for those who cannot benefit from PEBD, an alternative surgical procedure--ileal exclusion (IE)--was introduced. The aim of this study was to analyze our experience with IE in children with PFIC. METHODS This procedure was performed in 9 patients (6 girls, 3 boys) at the median age of 11 years (range 8-21). In 4 children, it was the primary operation (group 1), and in 5, IE was performed after PEBD (group 2). All of the patients were screened for ABCB11 and ATP8B1 mutations, and in 3 cases, PFIC type 2 was confirmed. RESULTS Median follow-up after IE surgery was 8.5 years (range 3-14). In group 1, 1 patient had to be converted to PEBD and the remaining 3 children experienced alleviation in pruritus and decrease in bilirubin and bile acids concentrations 2 and 5 years after IE. After 10 years, only 2 children were still accessible for follow-up. In both, pruritus varied and elevated serum bile acids were observed. Of the 5 patients who underwent IE after PEBD, 1 eventually required liver transplantation, 1 developed varying degree of pruritus, and 3 female patients, operated on because of aesthetic reasons, had excellent outcomes. CONCLUSIONS IE is an alternative rescue option to PEBD and should be offered cautiously, only to patients who cannot benefit from PEBD.
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Saber S, Vazifehmand R, Bagherizadeh I, Kasiri M. A novel ABCB11 mutation in an Iranian girl with progressive familial intrahepatic cholestasis. INDIAN JOURNAL OF HUMAN GENETICS 2013; 19:366-8. [PMID: 24339557 PMCID: PMC3841569 DOI: 10.4103/0971-6866.120813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Progressive familial intrahepatic cholestasis is an autosomal recessive liver disorder caused by (biallelic) mutations in the ATP8B1 of ABCB11 gene. A nine-year-old girl with cholestasis was referred for genetic counseling. She had a family history of cholestasis in two previous expired siblings. Genetic analysis of the ABCB11 gene led to the identification of a novel homozygous mutation in exon 25. The mutation 3593- A > G lead to a missense mutation at the amino acid level (His1198Arg). This mutation caused PFIC2 due to abnormal function in the bile salt export pump protein (BSEP).
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Affiliation(s)
- Sassan Saber
- Genetics Center, Shariati Hospital, Tehran Medical University, Tehran, Iran
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Pedersen JM, Matsson P, Bergström CAS, Hoogstraate J, Norén A, LeCluyse EL, Artursson P. Early identification of clinically relevant drug interactions with the human bile salt export pump (BSEP/ABCB11). Toxicol Sci 2013; 136:328-43. [PMID: 24014644 PMCID: PMC3858191 DOI: 10.1093/toxsci/kft197] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
A comprehensive analysis was performed to investigate how inhibition of the human bile salt export pump (BSEP/ABCB11) relates to clinically observed drug-induced liver injury (DILI). Inhibition of taurocholate (TA) transport was investigated in BSEP membrane vesicles for a data set of 250 compounds, and 86 BSEP inhibitors were identified. Structure-activity modeling identified BSEP inhibition to correlate strongly with compound lipophilicity, whereas positive molecular charge was associated with a lack of inhibition. All approved drugs in the data set (n = 182) were categorized according to DILI warnings in drug labels issued by the Food and Drug Administration, and a strong correlation between BSEP inhibition and DILI was identified. As many as 38 of the 61 identified BSEP inhibitors were associated with severe DILI, including 9 drugs not previously linked to BSEP inhibition. Further, among the tested compounds, every second drug associated with severe DILI was a BSEP inhibitor. Finally, sandwich-cultured human hepatocytes (SCHH) were used to investigate the relationship between BSEP inhibition, TA transport, and clinically observed DILI in detail. BSEP inhibitors associated with severe DILI greatly reduced the TA canalicular efflux, whereas BSEP inhibitors with less severe or no DILI resulted in weak or no reduction of TA efflux in SCHH. This distinction illustrates the usefulness of SCHH in refined analysis of BSEP inhibition. In conclusion, BSEP inhibition in membrane vesicles was found to correlate to DILI severity, and altered disposition of TA in SCHH was shown to separate BSEP inhibitors associated with severe DILI from those with no or mild DILI.
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Affiliation(s)
- Jenny M Pedersen
- *Department of Pharmacy, Uppsala University, SE-751 23 Uppsala, Sweden
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The bile salt export pump (BSEP) in health and disease. Clin Res Hepatol Gastroenterol 2012; 36:536-53. [PMID: 22795478 DOI: 10.1016/j.clinre.2012.06.006] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 05/29/2012] [Accepted: 06/06/2012] [Indexed: 02/04/2023]
Abstract
The bile salt export pump (BSEP) is the major transporter for the secretion of bile acids from hepatocytes into bile in humans. Mutations of BSEP are associated with cholestatic liver diseases of varying severity including progressive familial intrahepatic cholestasis type 2 (PFIC-2), benign recurrent intrahepatic cholestasis type 2 (BRIC-2) and genetic polymorphisms are linked to intrahepatic cholestasis of pregnancy (ICP) and drug-induced liver injury (DILI). Detailed analysis of these diseases has considerably increased our knowledge about physiology and pathophysiology of bile secretion in humans. This review focuses on expression, localization, and function, short- and long-term regulation of BSEP as well as diseases association and treatment options for BSEP-associated diseases.
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Nicastro E, Stephenne X, Smets F, Fusaro F, de Magnée C, Reding R, Sokal EM. Recovery of graft steatosis and protein-losing enteropathy after biliary diversion in a PFIC 1 liver transplanted child. Pediatr Transplant 2012; 16:E177-82. [PMID: 21672103 DOI: 10.1111/j.1399-3046.2011.01514.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PFIC 1 is a genetic disorder characterized by hepatic and gastrointestinal disease, often requiring LT during childhood. Extrahepatic symptoms, such as diarrhea and malabsorption, do not improve or may be aggravated after LT, as graft steatosis or steatohepatitis as consequences of the interaction between transplanted liver and native bowel. We describe a patient with PFIC 1 who presented with cholestasis in infancy, who developed intractable pruritus and liver fibrosis. The child underwent living donor LT at 3.6 yr of age, and he early developed severe refractory diarrhea, secondary malabsorption with protein-losing enteropathy, and an early fatty liver disease trough graft steatohepatitis. As the response to cholestyramine was unsatisfactory, we decided to perform an EBD by using the jejunal loop used for the cholangiojejunostomy. Diarrhea resolved rapidly after surgery. He remained well after six months following biliary diversion, with normal stool output and no protein loss. We documented a dramatic improvement of graft steatosis at histology as well as normalization of liver function test. EBD can be considered a valuable treatment option to avoid organ disfunction and loss in PFIC 1 transplanted patients who develop graft steatohepatitis.
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Affiliation(s)
- Emanuele Nicastro
- Département de Pédiatrie, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
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Kaur S, Sharma D, Wadhwa N, Gupta S, Chowdhary SK, Sibal A. Therapeutic interventions in progressive familial intrahepatic cholestasis: experience from a tertiary care centre in north India. Indian J Pediatr 2012; 79:270-3. [PMID: 21769524 DOI: 10.1007/s12098-011-0516-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Accepted: 06/20/2011] [Indexed: 12/24/2022]
Abstract
Medical therapy has limited value in managing symptoms of progressive familial intrahepatic cholestasis (PFIC). Liver transplantation (LT) is the only definite therapy for progressive liver failure and intractable pruritis. In recent years, biliary diversion (BD) has also shown therapeutic promise. This study was designed to review the experience of management and outcome of seven PFIC patients. Two children each had type II and III and three had type I/II PFIC, respectively. Medical treatment was successful in only one. Decompensated cirrhosis had already set in four children. They underwent a living related LT. There was one post transplant mortality. Remaining all children had a normal graft function at a mean follow-up of 50 months. One patient of PFIC type I/II received internal and another of PFIC type II received external BD. Both patients were asymptomatic at follow-up of 19 and 23 months respectively. Nontransplant surgical options should be offered to noncirrhotic children with PFIC.
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Affiliation(s)
- Satvinder Kaur
- Pediatric Gastroenterology and Hepatology, Apollo Centre of Advanced Pediatrics, Indraprastha Apollo Hospital, New Delhi 110076, India
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Wang H, Yan Z, Dong M, Zhu X, Wang H, Wang Z. Alteration in placental expression of bile acids transporters OATP1A2, OATP1B1, OATP1B3 in intrahepatic cholestasis of pregnancy. Arch Gynecol Obstet 2011; 285:1535-40. [PMID: 22203093 DOI: 10.1007/s00404-011-2183-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 12/14/2011] [Indexed: 12/17/2022]
Abstract
PURPOSE To investigate whether bile acids transporters organic anion transporting polypeptides 1A2 (OATP1A2), organic anion transporting polypeptides 1B1 (OATP1B1), organic anion transporting polypeptides 1B3 (OATP1B3) were differently expressed in placenta of intrahepatic cholestasis of pregnancy (ICP). METHODS Thirty pregnant women with ICP were recruited and 30 normal pregnant women served as control. The expression of mRNA and protein were analyzed by real-time PCR and Western blotting. The localization of OATP1A2, OATP1B1, OATP1B3 were investigated by immunohistochemistry. RESULTS The expression of mRNA and protein of both OATP1A2 and OATP1B3 were significantly lower in ICP placenta than normal placenta (P < 0.05). OATP1B1 mRNA was detected by RT-PCR in 8 ICP placentas and 7 control placentas, but protein expression of OATP1B1 was not found in any of the 60 placentas. By immunohistochemistry we found that OATP1A2 was obviously localized to vasculo-syncytial membrane (VSM) and apical surface of syncytiotrophoblasts, while OATP1B3 was localized to VSM of the syncytiotrophoblasts. CONCLUSIONS The expression of OATP1A2 and OATP1B3 in placenta decreased in ICP. The down-regulation of these transporters may be involved in the pathophysiology of ICP.
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Affiliation(s)
- Huimin Wang
- Women's Hospital, School of Medicine, Zhejiang University, 2 Xueshi Road, Hangzhou 310006, China
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Arnell H, Fischler B, Bergdahl S, Schnell PO, Jacobsson H, Nemeth A. Hepatobiliary scintigraphy during cholestatic and noncholestatic periods in patients with progressive familial intrahepatic cholestasis after partial external biliary diversion. J Pediatr Surg 2011; 46:467-72. [PMID: 21376194 DOI: 10.1016/j.jpedsurg.2010.09.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 09/15/2010] [Accepted: 09/16/2010] [Indexed: 12/29/2022]
Abstract
BACKGROUND The purpose of the study was to determine the distribution of excreted bile during cholestatic periods and in remission in patients with progressive familial intrahepatic cholestasis (PFIC) after surgery with partial external biliary diversion (PEBD), using hepatobiliary scintigraphy. METHODS Using intravenously administered technetium Tc 99m-labeled mebrofenin, the distribution of bile during periods of biochemical cholestasis and in remission was investigated in patients with PFIC operated with PEBD. Stomal bile, urine, and feces from the patients were collected during 24 hours after administration of technetium Tc 99m-labeled mebrofenin; and the fractions of remaining radioactivity in the 3 compartments and the remaining isotopic activity in the body were quantified using scintigraphy. RESULTS Nine patients (4 boys and 5 girls) were studied. The median age was 13 (range, 5-24) years, and they had been operated with PEBD at a median time of 10 (range, 4-14) years before entering the study. Thirteen scintigraphic examinations were analyzed: 8 during noncholestatic remission (n = 7 patients) and 5 during cholestasis (n = 3 patients). The patients studied during remission discharged a significantly larger fraction of isotopic activity through the stoma (median, 90% vs 22%; P < .05) and a significantly lower fraction through the urine (median, 2.5% vs 15%; P < .05) compared with the patients studied during cholestasis. CONCLUSION Hepatobiliary scintigraphy could detect substantial differences in the output of bile. Further studies are needed to determine whether these differences may explain the mechanism of the PEBD operation or merely are secondary to the degree of cholestasis.
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Affiliation(s)
- Henrik Arnell
- Division of Pediatrics, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Huddinge and Solna, Stockholm, Sweden.
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Clifton MS, Romero R, Ricketts RR. Button cholecystostomy for management of progressive familial intrahepatic cholestasis syndromes. J Pediatr Surg 2011; 46:304-7. [PMID: 21292078 DOI: 10.1016/j.jpedsurg.2010.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Accepted: 11/04/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE Progressive familial intrahepatic cholestasis syndromes are characterized by impaired bile acid secretion resulting in pruritus, coagulopathy, diarrhea, and malnutrition leading to progressive liver failure and death in childhood. Partial internal or external biliary drainage can relieve symptoms and slow the progression of the disease. Objections to partial external biliary drainage include the need for a permanent biliary stoma with all the inherent complications of a stoma. We propose a novel approach to these diseases--placement of a "button" cholecystostomy tube. METHODS Under general anesthesia and through a small right subcostal incision, a MIC-KEY button (Kimberly-Clark Worldwide, Inc, Draper, UT) is inserted into the mobilized fundus of the gallbladder and secured with 2 purse-string sutures. Time of drainage is adjusted to relieve pruritus. RESULTS Three children with progressive familial intrahepatic cholestasis achieved adequate bile drainage via the cholecystostomy button to relieve pruritus for 1, 2, and 2 ½ years postoperatively, with drainage periods of 12 to 14 hours per day. There were no episodes of cholangitis. Dislodged tubes can be replaced, or stones can be retrieved via the tract that is formed. Patient (parent) acceptance has been excellent. CONCLUSION Button cholecystostomy is simple to perform, relieves pruritus with intermittent (nighttime) drainage, avoids complications of a permanent stoma, avoids an enteric anastomosis, and is accepted by parents.
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Affiliation(s)
- Matthew S Clifton
- Division of Pediatric Surgery, Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA 30322, USA
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Clinical features and genotype-phenotype correlations in children with progressive familial intrahepatic cholestasis type 3 related to ABCB4 mutations. J Pediatr Gastroenterol Nutr 2011; 52:73-83. [PMID: 21119540 DOI: 10.1097/mpg.0b013e3181f50363] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The aim of the study was to estimate the frequency of ABCB4 mutations among children with chronic intrahepatic cholestasis with elevated gamma-glutamyl-transpeptidase (γ-GT) activity and to characterize the genotypes with respect to severity of symptoms, response to ursodeoxycholic acid therapy, and outcome. PATIENTS AND METHODS Molecular analysis of ABCB4 in 133 Italian children was performed, and ABCB4 mutations were classified as disease-causing mutations or benign substitutions according to the prediction algorithm PolyPhen. RESULTS : Twenty-eight patients were identified carrying 31 mutations (20 disease causing). Twenty patients carried 2 mutated alleles and 8 only 1. At presentation (1-204 months), 20 children were symptomatic with jaundice and/or pruritus, whereas in 8 biochemical cholestasis was a fortuitous finding. Cirrhosis developed in 15 and 6 progressed to terminal liver failure. Disease-causing mutations on both alleles were found to be associated with reduced liver expression of ABCB4 protein, lack of response to ursodeoxycholic acid therapy, and progression to cirrhosis and end-stage liver disease, whereas mild genotypes, including single heterozygous mutations, were generally associated with less severe disease and, often, absence of symptoms. CONCLUSIONS ABCB4 mutations are responsible for a chronic liver disease in more than one-third of patients with chronic intrahepatic cholestasis and elevated γ-GT activity. In patients with severe ABCB4 genotype, the disease is often progressive with risk of developing cirrhosis and liver failure during the first 2 decades of life. Patients with mild genotypes, including single heterozygous mutations, have variable expressions of liver disease that may be influenced by comorbidity factors and modulated by still unknown genetic modifiers.
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Sharma D, Shah UH, Sibal A, Chowdhary SK. Cholecystoappendicostomy for progressive familial intrahepatic cholestasis. Indian Pediatr 2010; 47:626-8. [PMID: 20683116 DOI: 10.1007/s13312-010-0122-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
We report a rare case of progressive familial intrahepatic cholestasis type 2 from India. The diagnosis was confirmed on the basis of gene mutation analysis. The child had intense pruritus refractory to conventional medical management. As liver biopsy did not reveal any cirrhosis, partial external biliary diversion was considered as an alternative to liver transplant. We performed cholecystoappendicostomy rather than the conventional method of using an ileal loop as a conduit between the gall bladder and abdominal wall. Child recovered completely.
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Affiliation(s)
- Deepa Sharma
- Division of Pediatric Gastroenterology and Pediatric Surgery, Apollo Centre for Advanced Pediatrics, Indraprastha Apollo Hospitals, New Delhi 110 076, India
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Arnell H, Papadogiannakis N, Zemack H, Knisely AS, Németh A, Fischler B. Follow-up in children with progressive familial intrahepatic cholestasis after partial external biliary diversion. J Pediatr Gastroenterol Nutr 2010; 51:494-9. [PMID: 20683202 DOI: 10.1097/mpg.0b013e3181df99d5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The aim of this study was to examine whether reversion of histological fibrosis followed partial external biliary diversion (PEBD) in patients with progressive familial intrahepatic cholestasis (PFIC); whether the duration of cholestatic episodes after PEBD influenced the evolution of fibrosis; and whether genotyping was helpful in predicting outcome of PEBD. PATIENTS AND METHODS Children with PFIC who underwent PEBD were investigated with genetic, biochemical, and anthropometric standard methods. Serial liver specimens were assessed histologically without knowledge of genotype and outcome. Findings were evaluated in the contexts of the total duration of cholestasis and the clinical outcome after PEBD. RESULTS From a total of 18 children with PFIC, 13 underwent PEBD, and 12 of these (among them 10 with identified ABCB11 mutations) were amenable for clinical and histological follow-up. When compared with baseline at PEBD, statistically significant reductions were found in histological cholestasis 1 and 3 years after PEBD, and in fibrosis 5 and >10 years after PEBD. The relative duration of cholestatic episodes after PEBD was positively correlated with the severity of fibrosis. Children homozygous for the missense mutation c.890A>G in ABCB11 responded well to PEBD. CONCLUSIONS Biliary diversion should be regarded as the first choice of surgical treatment in noncirrhotic patients with severe ABCB11 disease and may also be efficacious in other forms of PFIC.
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Affiliation(s)
- Henrik Arnell
- Department of Pediatrics, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
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van der Woerd WL, van Mil SWC, Stapelbroek JM, Klomp LWJ, van de Graaf SFJ, Houwen RHJ. Familial cholestasis: progressive familial intrahepatic cholestasis, benign recurrent intrahepatic cholestasis and intrahepatic cholestasis of pregnancy. Best Pract Res Clin Gastroenterol 2010; 24:541-53. [PMID: 20955958 DOI: 10.1016/j.bpg.2010.07.010] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 07/16/2010] [Accepted: 07/22/2010] [Indexed: 01/31/2023]
Abstract
Progressive familial intrahepatic cholestasis (PFIC) type 1, 2 and 3 are due to mutations in ATP8B1, ABCB11 and ABCB4, respectively. Each of these genes encodes a hepatocanalicular transporter, which is essential for the proper formation of bile. Mutations in ABCB4 can result in progressive cholestatic disease, while mutations in ATP8B1 and ABCB11 can result both in episodic cholestasis, referred to as benign recurrent intrahepatic cholestasis (BRIC) type 1 and 2, as well as in progressive cholestatic disease. This suggests a clinical continuum and these diseases are therefore preferably referred to as ATP8B1 deficiency and ABCB11 deficiency. Similarly PFIC type 3 is designated as ABCB4 deficiency. Heterozygous mutations in each of these transporters can also be associated with intrahepatic cholestasis of pregnancy. This review summarizes the pathophysiology, clinical features and current as well as future therapeutic options for progressive familial- and benign recurrent intrahepatic cholestasis as well as intrahepatic cholestasis of pregnancy.
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Affiliation(s)
- Wendy L van der Woerd
- Department of Paediatric Gastroenterology (KE.01.144.3), Wilhelmina Children's Hospital, University Medical Centre Utrecht, Post-Box 85090, 3508 AB Utrecht, The Netherlands.
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Dynamic regulation of cardiolipin by the lipid pump Atp8b1 determines the severity of lung injury in experimental pneumonia. Nat Med 2010; 16:1120-1127. [PMID: 20852622 PMCID: PMC4500192 DOI: 10.1038/nm.2213] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Accepted: 08/17/2010] [Indexed: 12/12/2022]
Abstract
Pneumonia remains the leading cause of infectious deaths and yet fundamentally new conceptual models underlying its pathogenesis have not emerged. Patients and mice with bacterial pneumonia have marked elevations of cardiolipin in lung fluid, a rare, mitochondrial-specific phospholipid that potently disrupts surfactant function. Intratracheal cardiolipin in mice recapitulates the clinical phenotype of pneumonia including impaired lung mechanics, modulation of cell survival and cytokine networks, and lobar consolidation. We have identified and characterized the activity of a novel cardiolipin transporter, ATP8b1, a mutant version of which is associated with severe pneumonia in humans and mice. ATP8b1 bound and internalized cardiolipin from extracellular fluid via a basic residue-enriched motif. Administration of cardiolipin binding motif peptide or ATP8b1 gene transfer in mice lessened lung injury and improved survival. The results unveil a new paradigm whereby ATP8b1 is a cardiolipin importer but its capacity to remove cardiolipin from lung fluid is exceeded during inflammation or ATP8b1 inefficiency. This discovery opens the door for new therapeutic strategies directed at modulating cardiolipin levels or its molecular interactions in pneumonia.
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An outstanding non-transplant surgical intervention in progressive familial intrahepatic cholestasis: partial internal biliary diversion. Pediatr Surg Int 2010; 26:831-4. [PMID: 20563871 DOI: 10.1007/s00383-010-2638-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2010] [Indexed: 12/19/2022]
Abstract
AIM Progressive familial intrahepatic cholestasis (PFIC) is a hereditary disease with severe cholestasis progressing to cirrhosis and chronic renal failure usually during the first decade. An alternative approach is partial diversion of bile. The aim of this study is to describe four patients with PFIC who underwent partial internal biliary diversion (PIBD). METHODS Review of three patients, their clinical, laboratory and histologic workups to evaluate the short-term effects of PFIC, a 1-year follow-up. For PIBD, a conduit is performed between the terminolateral side of the gall bladder and distal colon using a segment of jejunum, to divert the biliary flow from the enterohepatic cycle without any external stoma. RESULTS All four patients were presented with jaundice, pruritus, hepatomegaly, sleep disturbance. They fulfilled the criteria for PFIC. The surgery was uneventful. At follow-up, biochemical parameters improved significantly, growth was regained, relief in pruritus, sleeping pattern was normalized. CONCLUSIONS Partial internal biliary diversion had a dramatic effect on cholestasis, growth, sleeping and biochemical parameters. It also avoids the disadvantages of a permanent stoma. We believe that it is one of the best surgical procedures ever described for PFIC. Since long-term results of partial external biliary diversion on liver histopathology are successful, we hope that our long-term results will also be similar.
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Pawlikowska L, Strautnieks S, Jankowska I, Czubkowski P, Emerick K, Antoniou A, Wanty C, Fischler B, Jacquemin E, Wali S, Blanchard S, Nielsen IM, Bourke B, McQuaid S, Lacaille F, Byrne JA, van Eerde AM, Kolho KL, Klomp L, Houwen R, Bacchetti P, Lobritto S, Hupertz V, McClean P, Mieli-Vergani G, Shneider B, Nemeth A, Sokal E, Freimer NB, Knisely A, Rosenthal P, Whitington PF, Pawlowska J, Thompson RJ, Bull LN. Differences in presentation and progression between severe FIC1 and BSEP deficiencies. J Hepatol 2010; 53:170-8. [PMID: 20447715 PMCID: PMC3042805 DOI: 10.1016/j.jhep.2010.01.034] [Citation(s) in RCA: 130] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2009] [Revised: 01/11/2010] [Accepted: 01/12/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Progressive familial intrahepatic cholestasis (PFIC) with normal serum levels of gamma-glutamyltranspeptidase can result from mutations in ATP8B1 (encoding familial intrahepatic cholestasis 1 [FIC1]) or ABCB11 (encoding bile salt export pump [BSEP]). We evaluated clinical and laboratory features of disease in patients diagnosed with PFIC, who carried mutations in ATP8B1 (FIC1 deficiency) or ABCB11 (BSEP deficiency). Our goal was to identify features that distinguish presentation and course of these two disorders, thus facilitating diagnosis and elucidating the differing consequences of ATP8B1 and ABCB11 mutations. METHODS A retrospective multi-center study was conducted, using questionnaires and chart review. Available clinical and biochemical data from 145 PFIC patients with mutations in either ATP8B1 (61 "FIC1 patients") or ABCB11 (84 "BSEP patients") were evaluated. RESULTS At presentation, serum aminotransferase and bile salt levels were higher in BSEP patients; serum alkaline phosphatase values were higher, and serum albumin values were lower, in FIC1 patients. Elevated white blood cell counts, and giant or multinucleate cells at liver biopsy, were more common in BSEP patients. BSEP patients more often had gallstones and portal hypertension. Diarrhea, pancreatic disease, rickets, pneumonia, abnormal sweat tests, hearing impairment, and poor growth were more common in FIC1 patients. Among BSEP patients, the course of disease was less rapidly progressive in patients bearing the D482G mutation. CONCLUSIONS Severe forms of FIC1 and BSEP deficiency differed. BSEP patients manifested more severe hepatobiliary disease, while FIC1 patients showed greater evidence of extrahepatic disease.
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Affiliation(s)
- Ludmila Pawlikowska
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA,Institute for Human Genetics, University of California, San Francisco, San Francisco, CA
| | - Sandra Strautnieks
- Institute of Liver Studies, King’s College London School of Medicine, London, UK
| | - Irena Jankowska
- Department of Gastroenterology, Hepatology, and Immunology, Children’s Memorial Health Institute, Warsaw, Poland
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, and Immunology, Children’s Memorial Health Institute, Warsaw, Poland
| | - Karan Emerick
- Department of Pediatrics, University of Connecticut, Hartford, CT
| | | | - Catherine Wanty
- Pediatric Gastro-Enterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Bjorn Fischler
- Department of Pediatrics, Karolinska University Hospital, Huddinge, CLINTEC, Sweden
| | - Emmanuel Jacquemin
- Hépatologie Pédiatrique, CHU Bicêtre, Assistance Publique-Hôpitaux de Paris and INSERM U757, University of Paris Sud 11, Paris, France
| | - Sami Wali
- Department of Pediatrics, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia
| | - Samra Blanchard
- Department of Pediatric Gastroenterology, University of Maryland, College Park, MD
| | - Inge-Merete Nielsen
- Department of Cellular and Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Billy Bourke
- Children’s Research Center, Our Lady’s Children’s Hospital, Conway Institute, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Shirley McQuaid
- National Centre for Medical Genetics, Our Lady’s Children’s Hospital, Dublin, Ireland
| | - Florence Lacaille
- Department of Pediatrics, Hôpital Necker-Enfants Malades, Paris, France
| | - Jane A. Byrne
- Institute of Liver Studies, King’s College London School of Medicine, London, UK
| | | | - Kaija-Leena Kolho
- Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
| | - Leo Klomp
- Department of Metabolic and Endocrine Diseases, University Medical Center Utrecht, and Netherlands Metabolomics Center, Utrecht, The Netherlands
| | - Roderick Houwen
- Department of Pediatric Gastroenterology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter Bacchetti
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Steven Lobritto
- Center for Liver Disease and Transplantation, Columbia University, New York, NY
| | - Vera Hupertz
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, OH
| | - Patricia McClean
- Children’s Liver and Gastroenterology Unit, St. James’ University Hospital, Leeds, UK
| | | | - Benjamin Shneider
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Antal Nemeth
- Pediatric Gastroenterology, Hepatology, and Nutrition, Astrid Lindgren’s Children’s Hospital, Huddinge, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Etienne Sokal
- Laboratory of Pediatric Hepatology and Cell Therapy, Université Catholique de Louvain & Cliniques St Luc, Brussels, Belgium
| | - Nelson B. Freimer
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA
| | - A.S. Knisely
- Institute of Liver Studies, King’s College Hospital, London, UK
| | - Philip Rosenthal
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Peter F. Whitington
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Children’s Memorial Hospital, Chicago, IL
| | - Joanna Pawlowska
- Department of Gastroenterology, Hepatology, and Immunology, Children’s Memorial Health Institute, Warsaw, Poland
| | - Richard J. Thompson
- Institute of Liver Studies, King’s College London School of Medicine, London, UK
| | - Laura N. Bull
- Institute for Human Genetics, University of California, San Francisco, San Francisco, CA,Liver Center Laboratory, University of California, San Francisco, San Francisco, CA,To whom correspondence should be addressed: L. N. Bull, Ph.D., UCSF Liver Center Laboratory, San Francisco General Hospital, 1001 Potrero Avenue, Building 40, Room 4102, San Francisco, CA 94110, Phone: (415) 206-4807, Fax: (415) 641-0517,
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