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Kinuani R, Ezri J, Kernen Y, Rochat I, Blanchon S. Case Report: When cystic fibrosis, elexacaftor/tezacaftor/ivacaftor therapy, and alpha1 antitrypsin deficiency get together. Front Pediatr 2024; 12:1378744. [PMID: 38655277 PMCID: PMC11035779 DOI: 10.3389/fped.2024.1378744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/13/2024] [Indexed: 04/26/2024] Open
Abstract
In the last 10 years, the care of patients with cystic fibrosis (CF) has been revolutionized with the introduction of cystic fibrosis transmembrane conductance regulator (CFTR) modulator drugs, with a major impact on symptoms and life expectancy, especially considering the newest and highly effective elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) therapy. Conversely, adverse effects are relatively frequent, with some being life-threatening, such as severe hepatitis. Clinical trials on children starting CFTR modulators have reported transaminase elevations >3× upper limit of the norm in 10%-20% of patients, whereas real-life studies have reported discontinuation rates three times higher than those observed in phase 3 trials. We report the case of a 10-year-old boy with CF who developed severe acute hepatitis 2 weeks after starting ELX/TEZ/IVA therapy. An extensive screening for potential causes led to the identification of heterozygous alpha1-antitrypsin (AAT) deficiency with genotype MZ. The Z allele of SERPINA1 gene, encoding AAT, is known as a risk factor for CF liver disease. We hypothesized that it may act as a risk factor for drug-induced liver injury from CFTR modulators, notably ELX/TEZ/IVA. Therefore, checking AAT before starting CFTR modulator therapy can be suggested, in particular for children with previous, even transient, liver disease.
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Affiliation(s)
- Rachel Kinuani
- Pediatric Pulmonology and Cystic Fibrosis Unit, Department Women-Mother-Child, Service of Pediatrics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Department of Pediatrics, Divisions of Pediatrics Pulmonology, University Hospital Liège, Liège, Belgium
| | - Jessica Ezri
- Pediatric Gastro-Enterology Unit, Department Women-Mother-Child, Service of Pediatrics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Yann Kernen
- General Pediatric Private Practice, Yverdon-les-Bains, Switzerland
| | - Isabelle Rochat
- Pediatric Pulmonology and Cystic Fibrosis Unit, Department Women-Mother-Child, Service of Pediatrics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sylvain Blanchon
- Pediatric Pulmonology and Cystic Fibrosis Unit, Department Women-Mother-Child, Service of Pediatrics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Anton-Păduraru DT, Azoicăi AN, Trofin F, Murgu AM, Mîndru DE, Bocec AS, Halițchi COI, Zota GR, Păduraru D, Nastase EV. Diagnosis, Management, and Prognosis of Cystic Fibrosis-Related Liver Disease in Children. Diagnostics (Basel) 2024; 14:538. [PMID: 38473009 DOI: 10.3390/diagnostics14050538] [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: 01/23/2024] [Revised: 02/28/2024] [Accepted: 03/01/2024] [Indexed: 03/14/2024] Open
Abstract
Cystic fibrosis (CF) is a multifaceted disorder predominantly investigated for its pulmonary manifestations, yet patients with CF also exhibit a spectrum of extrapulmonary manifestations, notably those involving the hepatobiliary system. The latter constitutes the third leading cause of morbidity and mortality in individuals with CF. Cystic fibrosis-related liver disease (CFLD), with an escalating prevalence, manifests diverse clinical presentations ranging from hepatomegaly to cirrhosis and hepatopulmonary syndrome. Consequently, early detection and appropriate management are imperative for sustaining the health and influencing the quality of life of CF patients afflicted with CFLD. This review aims to consolidate existing knowledge by providing a comprehensive overview of hepatobiliary manifestations associated with CF. It delineates the clinical hepatobiliary manifestations, diagnostic methodologies, incorporating minimally invasive markers, and therapeutic approaches, encompassing the impact of novel CFTR modulators on CFLD. Given the exigency of early diagnosis and the intricate management of CFLD, a multidisciplinary team approach is essential to optimize care and enhance the quality of life for this subset of patients. In conclusion, recognizing CF as more than solely a pulmonary ailment, the authors underscore the imperative for further clinical investigations to establish a more robust evidence base for CFLD management within the continuum of this chronic disease.
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Affiliation(s)
- Dana-Teodora Anton-Păduraru
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
- "Sf. Maria" Children Emergency Hospital, 700309 Iasi, Romania
| | - Alice Nicoleta Azoicăi
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
- "Sf. Maria" Children Emergency Hospital, 700309 Iasi, Romania
| | - Felicia Trofin
- Department of Preventive Medicine and Interdisciplinarity-Microbiology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
| | - Alina Mariela Murgu
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
- "Sf. Maria" Children Emergency Hospital, 700309 Iasi, Romania
| | - Dana Elena Mîndru
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
- "Sf. Maria" Children Emergency Hospital, 700309 Iasi, Romania
| | - Ana Simona Bocec
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
| | | | - Gabriela Rusu Zota
- Department of Pharmacology, Clinical Pharmacology and Algesiology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Diana Păduraru
- "Dr. C. I. Parhon" Clinical Hospital, 700503 Iaṣi, Romania
| | - Eduard Vasile Nastase
- Department of Internal Medicine II-Infectious Diseases, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Clinical Hospital of Infectious Diseases "Sf. Parascheva", 700116 Iasi, Romania
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Lieu N, Prentice BJ, Field P, Fitzgerald DA. Trials and tribulations of highly effective modulator therapies in cystic fibrosis. Paediatr Respir Rev 2023; 48:10-19. [PMID: 37914566 DOI: 10.1016/j.prrv.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 11/03/2023]
Abstract
Highly effective modulator therapies (HEMTs) have revolutionised the management approach of most patients living with cystic fibrosis (CF) who have access to these therapies. Clinical trials have reported significant improvements across multiorgan systems, with patients surviving longer. However, there are accumulating case reports and observational data describing various adverse events following initiation of HEMTs including drug-to-drug interactions, drug induced liver injury, Stevens-Johnson syndrome, and neurocognitive symptoms including psychosis and depression, which have required discontinuation of therapy. Current clinical trials are assessing efficacy in younger patients with CF, yet long-term studies are also required to better understand the safety profile in the real-world setting across all ages and the impact of HEMT dose alteration or discontinuation.
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Affiliation(s)
- Nathan Lieu
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia, 2145; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia.
| | - Bernadette J Prentice
- Department of Respiratory Medicine, Sydney Children's Hospital, Randwick, Sydney, New South Wales, Australia, 2031; Discipline of Paediatrics and Child Health, UNSW, Sydney, New South Wales, Australia
| | - Penelope Field
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia, 2145; Department of Respiratory Medicine, Sydney Children's Hospital, Randwick, Sydney, New South Wales, Australia, 2031; Discipline of Paediatrics and Child Health, UNSW, Sydney, New South Wales, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia, 2145; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, New South Wales, Australia
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Costa JM, Pinto SM, Santos-Silva E, Moreira-Silva H. Incidental hypertransaminasemia in children-a stepwise approach in primary care. Eur J Pediatr 2023; 182:1601-1609. [PMID: 36697884 PMCID: PMC9877494 DOI: 10.1007/s00431-023-04825-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/10/2023] [Accepted: 01/15/2023] [Indexed: 01/27/2023]
Abstract
Children with elevated liver enzymes are occasionally discovered through laboratory work-up from different clinical scenarios. Although the majority will have transient and/or benign conditions, a subgroup will have underlying liver disorders. The differential diagnosis is broad and therefore, a systematic approach is of utmost importance. In this article, we reviewed the most recent and relevant literature to provide a comprehensive overview of the main disease processes that cause hypertransaminasemia in children. Ultimately, we propose a practical stepwise approach to guide primary care physicians in the evaluation of abnormal liver enzymes in asymptomatic children. The first step is to obtain a complete history along with a thorough physical examination to exclude red flags, which should dictate urgent consultation with a paediatric gastroenterologist or hepatologist. Conclusion: Hypertransaminasemia is a challenging scenario in the primary care setting. The aetiology can be broad, ranging from hepatic and extrahepatic to transient versus chronic liver disease. Timely referral to a specialised centre is of paramount importance for conducting targeted research and to not miss the chance of identifying a progressive, but still asymptomatic, treatable liver disease. What is Known: • Elevated liver enzyme is a challenging scenario in the primary care setting. • There are few studies guiding the evaluation of asymptomatic hypertransaminasemia in the paediatric population and a standardised approach is lacking. What is New: • We propose a practical stepwise approach to guide primary care physicians in the evaluation of abnormal liver enzymes.
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Affiliation(s)
- Joana Meneses Costa
- Valbom Family Health Unit, Group of Health Centers of Gondomar, Porto, Portugal
| | - Sara Martins Pinto
- Nascente Family Health Unit, Group of Health Centers of Gondomar, Porto, Portugal
| | - Ermelinda Santos-Silva
- Pediatrics Division, Gastroenterology Unit, Centro Hospitalar Universitário do Porto, Centro Materno Infantil do Norte, Largo da Maternidade No 45. 4050-651, Porto, Portugal
- Integrated Master in Medicine, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
- REQUIMTE, Laboratory of Biochemistry, Department of Biological Sciences, Faculdade de Farmácia, UCIBIO, Universidade do Porto, Porto, Portugal
| | - Helena Moreira-Silva
- Pediatrics Division, Gastroenterology Unit, Centro Hospitalar Universitário do Porto, Centro Materno Infantil do Norte, Largo da Maternidade No 45. 4050-651, Porto, Portugal.
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Yu C, Kotsimbos T. Respiratory Infection and Inflammation in Cystic Fibrosis: A Dynamic Interplay among the Host, Microbes, and Environment for the Ages. Int J Mol Sci 2023; 24:ijms24044052. [PMID: 36835487 PMCID: PMC9966804 DOI: 10.3390/ijms24044052] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 02/22/2023] Open
Abstract
The interplay between airway inflammation and infection is now recognized as a major factor in the pathobiology in cystic fibrosis (CF). A proinflammatory environment is seen throughout the CF airway resulting in classic marked and enduring neutrophilic infiltrations, irreversibly damaging the lung. Although this is seen to occur early, independent of infection, respiratory microbes arising at different timepoints in life and the world environment perpetuate this hyperinflammatory state. Several selective pressures have allowed for the CF gene to persist until today despite an early mortality. Comprehensive care systems, which have been a cornerstone of therapy for the past few decades, are now revolutionized by CF transmembrane conductance regulator (CTFR) modulators. The effects of these small-molecule agents cannot be overstated and can be seen as early as in utero. For an understanding of the future, this review looks into CF studies spanning the historical and present period.
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Affiliation(s)
- Christiaan Yu
- Department of Respiratory Medicine, Alfred Health, Melbourne, VIC 3004, Australia
- Correspondence: ; Tel.: +61-3-9076-20000
| | - Tom Kotsimbos
- Department of Respiratory Medicine, Alfred Health, Melbourne, VIC 3004, Australia
- Department of Medicine, Monash University, Alfred Campus, Melbourne, VIC 3004, Australia
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Tabori H, Schneider J, Lüth S, Zagoya C, Barucha A, Lehmann T, Kauf E, Barth A, Mainz JG. Elevated Levels of Toxic Bile Acids in Serum of Cystic Fibrosis Patients with CFTR Mutations Causing Pancreatic Insufficiency. Int J Mol Sci 2022; 23:ijms232012436. [PMID: 36293293 PMCID: PMC9603931 DOI: 10.3390/ijms232012436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/29/2022] [Accepted: 10/03/2022] [Indexed: 11/16/2022] Open
Abstract
Hepatobiliary involvement is a hallmark in cystic fibrosis (CF), as the causative CF Transmembrane Conductance Regulator (CFTR) defect is expressed in the biliary tree. However, bile acid (BA) compositions in regard to pancreatic insufficiency, which is present at an early stage in about 85% of CF patients, have not been satisfactorily understood. We assess the pattern of serum BAs in people with CF (pwCF) without CFTR modulator therapy in regard to pancreatic insufficiency and the CFTR genotype. In 47 pwCF, 10 free and 12 taurine- and glycine-conjugated BAs in serum were prospectively assessed. Findings were related to genotype, pancreatic insufficiency prevalence (PIP)-score, and hepatic involvement indicated by serum liver enzymes, as well as clinical and ultrasound criteria for CF-related liver disease. Serum concentrations of total primary BAs and free cholic acid (CA) were significantly higher in pwCF with higher PIP-scores (p = 0.025, p = 0.009, respectively). Higher total BAs were seen in pwCF with PIP-scores ≥0.88 (p = 0.033) and with pancreatic insufficiency (p = 0.034). Free CA was higher in patients with CF-related liver involvement without cirrhosis, compared to pwCF without liver disease (2.3-fold, p = 0.036). pwCF with severe CFTR genotypes, as assessed by the PIP-score, reveals more toxic BA compositions in serum. Subsequent studies assessing changes in BA homeostasis during new highly effective CFTR-modulating therapies are of high interest.
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Affiliation(s)
- Harold Tabori
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, 14770 Brandenburg an der Havel, Germany
- Internal Medicine, Alexianer Hedwigshöhe Hospital, 12526 Berlin, Germany
| | - Jochen Schneider
- Cystic Fibrosis Centre, Jena University Hospital, 07740 Jena, Germany
| | - Stefan Lüth
- Department of Gastroenterology, Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, 14770 Brandenburg an der Havel, Germany
- Faculty of Health Sciences, Joint Faculty of the Brandenburg University of Technology Cottbus-Senftenberg, Brandenburg Medical School Theodor Fontane, University of Potsdam, 14469 Potsdam, Germany
| | - Carlos Zagoya
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, 14770 Brandenburg an der Havel, Germany
| | - Anton Barucha
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, 14770 Brandenburg an der Havel, Germany
| | - Thomas Lehmann
- Institute of Medical Statistics, Jena University Hospital, 07743 Jena, Germany
| | - Eberhard Kauf
- Cystic Fibrosis Centre, Jena University Hospital, 07740 Jena, Germany
| | - Astrid Barth
- Institut für Pharmakologie und Toxikologie, Jena University Hospital, 07743 Jena, Germany
| | - Jochen G. Mainz
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, 14770 Brandenburg an der Havel, Germany
- Cystic Fibrosis Centre, Jena University Hospital, 07740 Jena, Germany
- Faculty of Health Sciences, Joint Faculty of the Brandenburg University of Technology Cottbus-Senftenberg, Brandenburg Medical School Theodor Fontane, University of Potsdam, 14469 Potsdam, Germany
- Correspondence: ; Tel.: +49-3381-411800; Fax: +49-3381-411809
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Islek A, Tumgor G. Biliary atresia and congenital disorders of the extrahepatic bile ducts. World J Gastrointest Pharmacol Ther 2022; 13:33-46. [PMID: 36051179 PMCID: PMC9297290 DOI: 10.4292/wjgpt.v13.i4.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/10/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
Biliary atresia (BA) and choledochal cysts are diseases of the intrahepatic and extrahepatic biliary tree. While their exact etiopathogeneses are not known, they should be treated promptly due to the potential for irreversible parenchymal liver disease. A diagnosis of BA may be easy or complicated, but should not be delayed. BA is always treated surgically, and performing the surgery before the age of 2 mo greatly increases its effectiveness and extends the time until the need for liver transplantation arises. While the more common types of choledochal cysts require surgical treatment, some can be treated with endoscopic retrograde cholangiopancreatography. Choledochal cysts may cause recurrent cholangitis and the potential for malignancy should not be ignored.
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Affiliation(s)
- Ali Islek
- Department of Pediatric Gastroenterology, Cukurova University School of Medicine, Adana 01320, Turkey
| | - Gokhan Tumgor
- Department of Pediatric Gastroenterology, Cukurova University School of Medicine, Adana 01320, Turkey
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Neri LDCL, Simon MISDS, Ambrósio VLS, Barbosa E, Garcia MF, Mauri JF, Guirau RR, Neves MA, Cunha CDAP, Nogueira MC, Alves ACDC, Gurmini J, Servidoni MDF, Epifanio M, Athanazio R. Brazilian Guidelines for Nutrition in Cystic Fibrosis. EINSTEIN-SAO PAULO 2022; 20:eRW5686. [PMID: 35384985 PMCID: PMC8967313 DOI: 10.31744/einstein_journal/2022rw5686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 01/12/2021] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To develop a scientific consensus on nutrition in cystic fibrosis. METHODS Sixteen coordinators elaborated relevant questions on nutritional therapy in cystic fibrosis, which were divided into six sections: nutritional assessment, nutritional recommendations, nutritional intervention, dietary counseling, special situations and enzyme replacement, and gastrointestinal manifestations. Two to three specialists in the field were responsible for each section and obtaining answers formulated based on standardized bibliographic searches. The available literature was searched in the PubMed®/MEDLINE database, after training and standardization of search strategies, to write the best level of evidence for the questions elaborated. Issues related to disagreement were discussed until a consensus was reached among specialists, based on the current scientific literature. RESULTS Forty-two questions were prepared and objectively answered, resulting in a consensus of nutritional therapy in cystic fibrosis. CONCLUSION This work enabled establishing a scientific consensus for nutritional treatment of cystic fibrosis patients.
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Affiliation(s)
- Lenycia de Cassya Lopes Neri
- Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | - Eliana Barbosa
- Hospital Infantil Joana de Gusmão, Florianópolis, SC, Brazil
| | | | | | | | | | | | | | - Anna Carolina Di Creddo Alves
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | - Matias Epifanio
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Rodrigo Athanazio
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Cystic fibrosis-related liver disease: Clinical presentations, diagnostic and monitoring approaches in the era of CFTR modulator therapies. J Hepatol 2022; 76:420-434. [PMID: 34678405 DOI: 10.1016/j.jhep.2021.09.042] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/09/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022]
Abstract
Cystic fibrosis (CF) is the most common autosomal recessive disease in the Caucasian population. Cystic fibrosis-related liver disease (CFLD) is defined as the pathogenesis related to the underlying CFTR defect in biliary epithelial cells. CFLD needs to be distinguished from other liver manifestations that may not have any pathological significance. The clinical/histological presentation and severity of CFLD vary. The main histological presentation of CFLD is focal biliary fibrosis, which is usually asymptomatic. Portal hypertension develops in a minority of cases (about 10%) and may require specific management including liver transplantation for end-stage liver disease. Portal hypertension is usually the result of the progression of focal biliary fibrosis to multilobular cirrhosis during childhood. Nevertheless, non-cirrhotic portal hypertension as a result of porto-sinusoidal vascular disease is now identified increasingly more frequently, mainly in young adults. To evaluate the effect of new CFTR modulator therapies on the liver, the spectrum of hepatobiliary involvement must first be precisely classified. This paper discusses the phenotypic features of CFLD, its underlying physiopathology and relevant diagnostic and follow-up approaches, with a special focus on imaging.
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Advanced but not mild liver disease is a predictor of decreased survival in children with cystic fibrosis, with far greater impact in females: A 27-year real-life cohort study. J Cyst Fibros 2021; 21:230-235. [PMID: 34949555 DOI: 10.1016/j.jcf.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/19/2021] [Accepted: 11/23/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Improved survival of children with CF has increased our need to understand the relevance of cystic fibrosis-associated liver disease (CFLD). We assessed the impact of liver disease and disease severity on the survival of children with cystic fibrosis. METHODS A real life, single center cohort study with 27 years follow up was conducted. Mild CFLD was diagnosed as children with abnormal serum liver function tests and abnormal ultrasound. Advanced CFLD was established by detection of cirrhosis or portal hypertension. A directed acyclic graph, Kaplan-Meier (KM) and Cox regression analysis were used to model survival. RESULTS 290 patients were enrolled, 48 (16.5%) had mild CFLD and 55 (19%) had advanced CFLD. Ten children with advanced CFLD and 1 with mild CFLD died. Based on the KM analysis, the mean (SE) overall survival age of all CF children was 29.1 years (0.50). The mean (SE) survival among females with advanced CFLD was 24.7 years (1.58) compared to 30.4 years (0.66) for females without advanced CFLD (p = 0.0027). Advanced CFLD was a predictor of decreased survival when adjusted for sex and diabetes (HR 2.54, 95%CI 1.05-6.15, p = 0.039). Mild CFLD was not associated with decreased survival. The effect of advanced CFLD on survival was mainly borne by females (HR = 6.37, 95%CI 1.62-25.06 vs. males, HR = 1.00, 95%CI 0.25-4.01). CONCLUSION Advanced but not mild CFLD was associated with an increased risk of death when adjusted for sex and diabetes, and resulted in premature death in females with cystic fibrosis by approximately 6 years.
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Tosco A, Sepe A, Castaldo A, Catzola A, Cimbalo C, Angelini V, Vallone G, Buzzetti R, Raia V, Caprio MG. Non-invasive tools for detection of liver disease in children and adolescents with cystic fibrosis. Transl Pediatr 2021; 10:2952-2959. [PMID: 34976761 PMCID: PMC8649592 DOI: 10.21037/tp-21-68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 08/12/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Cystic fibrosis (CF) is a multi-organ genetic disease caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene which encodes the CFTR protein. CF-associated liver disease (CFLD) is a common complication; diagnosis is based on clinical, laboratory findings and abdominal imaging. However, non-invasive diagnostic approaches are needed to early detect CFLD, its progression and severity. Recent studies demonstrate a possible role of point shear wave elastography (p-SWE) with liver stiffness measurement (LSM) as a tool for CFLD diagnosis also in children. This non-invasive technique measures liver stiffness to assess liver fibrosis and is suggested to be less operator-dependent compared to ultrasonography. Aim of our prospective observational study is to investigate the role of p-SWE with LSM for CFLD diagnosis in children and adolescents with CF and to compare this finding with aspartate aminotransferase to platelet ratio index (APRI), fibrosis index based on four factors (FIB-4) and gamma-glutamyl-transpeptidase to platelet ratio (GPR) indices. METHODS Fifty-nine children with CF, who had routinely undergone abdominal imaging, were consecutively enrolled. Laboratory findings and clinical data were recorded, as abdominal ultrasound and shear wave elastography at baseline. The cases were divided into two groups based on collected data and classified as CFLD and CFnoLD (without liver disease) according to Debray criteria. APRI, FIB-4 and GPR fibrosis indices were also evaluated. RESULTS Twenty-four/59 (40.7%) were defined as CFLD. LSM test is superior to the APRI (P<0.001), the FIB-4 test (P=0.001) and the GPR test for early detection of liver fibrosis. LSM had an area under receiver operating characteristic (ROC) curve =0.818 (95% CI: 0.702-0.934) compared with APRI (0.571, 95% CI: 0.421-0.722), FIB-4 (0.656, 95% CI: 0.511-0.801) and GPR (0.632, 95% CI: 0.485-0.779). At a cut-off of ≥6.2 LSM show a sensitivity of 75.0% and a specificity of 88.6%. CONCLUSIONS LSM by transient p-SWE is a non-invasive, highly accessible, reliable, and reproducible test that can be used to assess early detection of liver fibrosis and its severity in children and adolescents with CF, limiting the use of liver biopsy. These preliminary observations point to the need of larger study population to confirm our data.
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Affiliation(s)
- Antonella Tosco
- Pediatric Unit, Department of Translational Medical Sciences, Regional Cystic Fibrosis Center, Federico II University of Naples, Naples, Italy
| | - Angela Sepe
- Pediatric Unit, Department of Translational Medical Sciences, Regional Cystic Fibrosis Center, Federico II University of Naples, Naples, Italy
| | - Alice Castaldo
- Pediatric Unit, Department of Translational Medical Sciences, Regional Cystic Fibrosis Center, Federico II University of Naples, Naples, Italy
| | - Andrea Catzola
- Pediatric Unit, Department of Translational Medical Sciences, Regional Cystic Fibrosis Center, Federico II University of Naples, Naples, Italy
| | - Chiara Cimbalo
- Pediatric Unit, Department of Translational Medical Sciences, Regional Cystic Fibrosis Center, Federico II University of Naples, Naples, Italy
| | - Valentina Angelini
- Department of Oncoematologia, Diagnostica per immagini e morfologica e Medicina Legale, University of Naples Federico II, Naples, Italy
| | - Gianfranco Vallone
- Department Life and Health "V. Tiberio", University of Molise, Campobasso, Italy
| | | | - Valeria Raia
- Pediatric Unit, Department of Translational Medical Sciences, Regional Cystic Fibrosis Center, Federico II University of Naples, Naples, Italy
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Martonosi ÁR, Soós A, Rumbus Z, Hegyi P, Izsák V, Pázmány P, Imrei M, Váncsa S, Szakács Z, Párniczky A. Non-invasive Diagnostic Tests in Cystic Fibrosis-Related Liver Disease: A Diagnostic Test Accuracy Network Meta-Analysis. Front Med (Lausanne) 2021; 8:598382. [PMID: 34386504 PMCID: PMC8353091 DOI: 10.3389/fmed.2021.598382] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 06/25/2021] [Indexed: 11/28/2022] Open
Abstract
Background and Aims: Cystic fibrosis-related liver disease (CFLD) is one of the leading causes of morbidity and mortality in cystic fibrosis (CF). Several non-invasive diagnostic methods have been proposed as screening tools for CFLD. Our aim was to rank all available non-invasive modalities for diagnostic performance. Methods: A systematic search was performed in five medical databases to find studies which reported on any single or composite non-invasive diagnostic test (as an index test) compared to the Debray, the EuroCare or the Colombo criteria (as a reference standard). Ranking was carried out with a Bayesian diagnostic test accuracy network meta-analysis based on superiority indices, calculated for pooled sensitivity (Se) and specificity (Sp) with a 95% confidence interval (CI). The study was registered under CRD42020155846 in PROSPERO. Results: Fifteen studies with 15 index tests and a combination of them were included. The New criteria proposed by Koh et al. – which represent a composite diagnostic definition for CFLD including liver biochemistry, ultrasonography, transient elastography and fibrosis markers—had the best performance for detecting CFLD (Se:94%[CI:58–100], Sp:72%[CI:52–84]); while transient elastography (Se:65%[CI:56–74], Sp:88%[CI:84–91]) and a combination of it with a tissue inhibitor of metalloproteinase-4 measurement (Se:78%[CI:30–100], Sp:64%[CI:18–95%]) proved to be the second and third best options, respectively. In the imaging techniques subgroup, transient elastography (Se:66%[CI:57–72], Sp:88%[CI:85–91%]), acoustic radiation force impulse in the right lobe (Se:54%[CI:33–74], Sp:88%[CI:66–96]) and that in the left lobe (Se:55%[CI:23–81], Sp:82%[CI:50–95]) were ranked the highest. Comparing biochemical markers/fibrosis indices, the measurement of the Forns index (Se:72%[CI:25–99], Sp:63%[CI:16–94]), the aspartate aminotransferase-to-platelet ratio (Se:55%[CI:41–68], Sp:83%[CI:66–89]) and alkaline phosphatase (Se:63%[CI:18–93], Sp:64%[CI:19–95]) were ranked the highest. Conclusion: The New criteria show the best diagnostic performance. In clinical practice, transient elastography seems to be a simple, cheap and non-invasive tool, outperforming imaging, biochemical and fibrosis tests for detecting CFLD. Further studies are needed to validate our findings.
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Affiliation(s)
- Ágnes Rita Martonosi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Alexandra Soós
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zoltán Rumbus
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Vera Izsák
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Piroska Pázmány
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Marcell Imrei
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Szilárd Váncsa
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Andrea Párniczky
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
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Abstract
Cystic fibrosis (CF) is one of the most commonly diagnosed genetic disorders. Clinical characteristics include progressive obstructive lung disease, sinusitis, exocrine pancreatic insufficiency leading to malabsorption and malnutrition, liver and pancreatic dysfunction, and male infertility. Although CF is a life-shortening disease, survival has continued to improve to a median age of 46.2 years due to earlier diagnosis through routine newborn screening, promulgation of evidence-based guidelines to optimize nutritional and pulmonary health, and the development of CF-specific interdisciplinary care centers. Future improvements in health and quality of life for individuals with CF are likely with the recent development of mutation-specific modulator therapies. In this review, we will cover the current understanding of the disease manifestations, diagnosis, and management as well as common complications seen in individuals with CF.
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Affiliation(s)
- Kimberly M Dickinson
- Eudowood Division of Pediatric Respiratory Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph M Collaco
- Eudowood Division of Pediatric Respiratory Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD
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The Extrapulmonary Effects of Cystic Fibrosis Transmembrane Conductance Regulator Modulators in Cystic Fibrosis. Ann Am Thorac Soc 2021; 17:147-154. [PMID: 31661636 PMCID: PMC6993798 DOI: 10.1513/annalsats.201909-671cme] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The effects of cystic fibrosis (CF) transmembrane conductance regulator (CFTR) modulators on lung function, pulmonary exacerbations, and quality of life have been well documented. However, CF is a multiorgan disease, and therefore an evidence base is emerging on the systemic effects of CFTR modulators beyond the pulmonary system. This is of great clinical importance, as many of these studies provide proof of concept that CFTR modulators might be used one day to prevent or treat extrapulmonary manifestations stemming from CFTR dysfunction. In this concise review of the literature, we summarize the results of key publications that have evaluated the effects of CFTR modulators on weight and growth, pancreatic function, the gastrointestinal and hepatobiliary systems, sinus disease, bone disease, exercise tolerance, fertility, mental health, and immunity. Although many of these studies have reported beneficial extrapulmonary effects related to the use of ivacaftor (IVA) in patients with CF with at least one gating mutation, most of the evidence is low or very low quality, given the limited number of patients evaluated and the lack of control groups. Based on an even smaller number of studies evaluating the extrapulmonary effects of lumacaftor-IVA, the benefits are less clear. Although limited, these studies may provide the basis for future clinical trials to evaluate CFTR modulators on the extrapulmonary manifestations of CF.
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15
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Hepatobiliary Involvement in Cystic Fibrosis. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Li H, Lin L, Hu X, Li C, Zhang H. Liver Failure in a Chinese Cystic Fibrosis Child With Homozygous R553X Mutation. Front Pediatr 2019; 7:36. [PMID: 30842938 PMCID: PMC6391319 DOI: 10.3389/fped.2019.00036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 01/28/2019] [Indexed: 12/25/2022] Open
Abstract
Cystic fibrosis (CF) is a relatively rare disease in Asians with various clinical characteristics, including CF-associated liver disease (CFLD), which is a common early non-pulmonary complication. This case report describes a Chinese CF patient harboring a homozygous nonsense mutation (c.1657C>T, p.R553X) who was failure to thrive and had intermittently diarrhea during the first year after birth. Liver function test of the patient showed the mildly and intermittently elevated alanine aminotransferase (ALT) levels ranging from 70 to 92 U/L and aspartate aminotransferase (AST) levels ranging from 80 to 90 U/L, which began at 8 months of age and lasted for 4 years without CF diagnosis. In addition, abdominal computed tomography (CT) revealed diffuse fatty infiltration of the liver at 4 years old and gradually developed hepatic cirrhosis. Subsequently, cirrhosis rapidly progressed with obvious splenomegaly and pancreatic insufficiency and the patient died of liver failure with coagulopathy by the age of 6 years old. Pediatricians should remain vigilant to avoid failure to diagnose CF, the occurrence of which may be underestimated, and pay greater attention to the patients with atypical clinical manifestations in Asian countries.
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Affiliation(s)
- Haiyan Li
- Department of Pediatric Pulmonology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Li Lin
- Department of Pediatric Pulmonology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaoguang Hu
- Department of Pediatric Pulmonology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Changchong Li
- Department of Pediatric Pulmonology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hailin Zhang
- Department of Pediatric Pulmonology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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van de Peppel IP, Bodewes FAJA, Verkade HJ, Jonker JW. Bile acid homeostasis in gastrointestinal and metabolic complications of cystic fibrosis. J Cyst Fibros 2018; 18:313-320. [PMID: 30201330 DOI: 10.1016/j.jcf.2018.08.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 12/18/2022]
Abstract
With the improved treatment of the pulmonary complications of cystic fibrosis (CF), gastrointestinal problems have become more important in the morbidity in CF. A hallmark of the gastrointestinal phenotype of CF, apart from pancreatic insufficiency, is a disruption of bile acid homeostasis. Bile acid homeostasis is important for many gastrointestinal processes including fat absorption, inflammation, microbial composition, as well as regulation of whole body energy metabolism. This review describes the impairment of bile acid homeostasis in CF, its possible consequences for gastrointestinal and metabolic complications and its potential as a target for therapy.
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Affiliation(s)
- Ivo P van de Peppel
- Pediatric Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, the Netherlands; Section of Molecular Metabolism and Nutrition, Department of Pediatrics, University of Groningen, University Medical Center Groningen, the Netherlands.
| | - Frank A J A Bodewes
- Pediatric Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Henkjan J Verkade
- Pediatric Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, the Netherlands; Section of Molecular Metabolism and Nutrition, Department of Pediatrics, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Johan W Jonker
- Section of Molecular Metabolism and Nutrition, Department of Pediatrics, University of Groningen, University Medical Center Groningen, the Netherlands.
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