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Yoeli D, Mack CL, Luo Y, Chaidez A, De La Rosa NL, Wang Z, Cervantes-Alvarez E, Huang CA, Navarro-Alvarez N. Galectin-3 in biliary atresia and other pediatric cholestatic liver diseases. Hepatol Res 2024; 54:392-402. [PMID: 37950561 DOI: 10.1111/hepr.13987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
AIMS Biliary atresia (BA) is characterized by intrahepatic inflammation and rapid progression of liver fibrosis. Galectin-3, a beta-galactoside binding protein, is a key regulator of inflammation and fibrosis. The aim of this study was to characterize circulating and hepatic Galectin-3 levels in children with BA. METHODS Plasma and liver samples were obtained from children with early BA at time of Kasai hepatoportoenterostomy, late BA at time of transplant, early and late other cholestatic liver diseases (CLD), and controls. Plasma Galectin-3 was measured using standard enzyme-linked immunoassay. Liver tissue was analyzed with multiplex immunohistochemistry and quantified using whole slide analysis. Statistical comparisons were made using nonparametric testing. RESULTS Plasma Galectin-3 in late BA was significantly higher than in early BA (20.82 [12.45-30.46] vs. 11.30 [8.74-16.83] ng/mL, p = 0.0096). Galectin-3 levels correlated with markers of disease severity and interleukin-6. There were significantly more Galectin-3+ M2 macrophages in late BA in comparison to late other CLD (162 [157-233] vs. 49 [33-59] cells/mm2, p = 0.03). The number of Galectin-3+ M2 macrophages correlated with the number of activated hepatic stellate cells and bile duct proliferation. CONCLUSIONS Plasma Galectin-3 is higher in late BA at time of transplant in comparison to early BA at time of Kasai. The number of Galectin-3 expressing M2 macrophages in late BA is elevated relative to late other CLD and was associated with other prognostic histological findings. Galectin-3 targeted therapy may be beneficial in slowing disease progression to cirrhosis in children with BA.
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Affiliation(s)
- Dor Yoeli
- Division of Transplant Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Cara L Mack
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Yuhuan Luo
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Alexander Chaidez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Nathaly Limon De La Rosa
- Division of Transplant Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Zhaohui Wang
- Division of Transplant Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Eduardo Cervantes-Alvarez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Christene A Huang
- Division of Transplant Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Nalu Navarro-Alvarez
- Division of Transplant Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Kemme S, Sokol RJ, Mack CL. Reply to: "Cytomegalovirus infection in patients with biliary atresia-further questions and possible solutions". Hepatol Commun 2024; 8:e0340. [PMID: 38260955 PMCID: PMC10805417 DOI: 10.1097/hc9.0000000000000340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 10/19/2023] [Indexed: 01/24/2024] Open
Affiliation(s)
- Sarah Kemme
- D. Brent Polk Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carrell Jr. Children’s Hospital at Vanderbilt Nashville, Tennessee, USA
| | - Ronald J. Sokol
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition University of Colorado School of Medicine and Children’s Hospital Colorado Aurora, Colorado, USA
| | - Cara L. Mack
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition Medical College of Wisconsin, Children’s Wisconsin, Milwaukee, Wisconsin, USA
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Yoeli D, Choudhury RA, Sundaram SS, Mack CL, Roach JP, Karrer FM, Wachs ME, Adams MA. Corrigendum to "Primary vs. Salvage Liver Transplantation for Biliary Atresia: A Retrospective Cohort Study" J Pediatr Surg 57 (2022) 407-413. J Pediatr Surg 2024; 59:165. [PMID: 37838616 DOI: 10.1016/j.jpedsurg.2023.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Affiliation(s)
- Dor Yoeli
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA.
| | - Rashikh A Choudhury
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Shikha S Sundaram
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, The Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Cara L Mack
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, The Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA; Division of Pediatric Gastroenterology, Department of Pediatrics, Hepatology & Nutrition, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
| | - Jonathan P Roach
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Frederick M Karrer
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Michael E Wachs
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Megan A Adams
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
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Thompson RJ, Artan R, Baumann U, Calvo PL, Czubkowski P, Dalgic B, D’Antiga L, Di Giorgio A, Durmaz Ö, Gonzalès E, Grammatikopoulos T, Gupte G, Hardikar W, Houwen RH, Kamath BM, Karpen SJ, Lacaille F, Lachaux A, Lainka E, Loomes KM, Mack CL, Mattsson JP, McKiernan P, Ni Q, Özen H, Rajwal SR, Roquelaure B, Shteyer E, Sokal E, Sokol RJ, Soufi N, Sturm E, Tessier ME, van der Woerd WL, Verkade HJ, Vittorio JM, Wallefors T, Warholic N, Yu Q, Horn P, Kjems L. Interim results from an ongoing, open-label, single-arm trial of odevixibat in progressive familial intrahepatic cholestasis. JHEP Rep 2023; 5:100782. [PMID: 37456676 PMCID: PMC10338319 DOI: 10.1016/j.jhepr.2023.100782] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 03/28/2023] [Accepted: 04/16/2023] [Indexed: 07/18/2023] Open
Abstract
Background & Aims PEDFIC 2, an ongoing, open-label, 72-week study, evaluates odevixibat, an ileal bile acid transporter inhibitor, in patients with progressive familial intrahepatic cholestasis. Methods PEDFIC 2 enrolled and dosed 69 patients across two cohorts; all received odevixibat 120 μg/kg per day. Cohort 1 comprised children from PEDFIC 1, and cohort 2 comprised new patients (any age). We report data through 15 July 2020, with Week 24 of PEDFIC 2 the main time point analysed. This represents up to 48 weeks of cumulative exposure for patients treated with odevixibat from the 24-week PEDFIC 1 study (cohort 1A) and up to 24 weeks of treatment for those who initiated odevixibat in PEDFIC 2 (patients who received placebo in PEDFIC 1 [cohort 1B] or cohort 2 patients). Primary endpoints for this prespecified interim analysis were change from baseline to Weeks 22-24 in serum bile acids (sBAs) and proportion of positive pruritus assessments (≥1-point drop from PEDFIC 2 baseline in pruritus on a 0-4 scale or score ≤1) over the 24-week period. Safety monitoring included evaluating treatment-emergent adverse events (TEAEs). Results In cohort 1A, mean change from PEDFIC 1 baseline to Weeks 22-24 of PEDFIC 2 in sBAs was -201 μmol/L (p <0.0001). For cohort 1B and cohort 2, mean changes from odevixibat initiation to weeks 22-24 in sBAs were -144 and -104 μmol/L, respectively. The proportion of positive pruritus assessments in the first 24-week period of PEDFIC 2 was 33%, 56%, and 62% in cohorts 1A, 1B, and 2, respectively. Most TEAEs were mild or moderate. No drug-related serious TEAEs occurred. Conclusions Odevixibat in patients with progressive familial intrahepatic cholestasis was generally well tolerated and associated with sustained reductions in sBAs and pruritus. Clinical Trials Registration This study is registered at ClinicalTrials.gov (NCT03659916). Impact and Implications Disrupted bile flow is a hallmark feature of patients with progressive familial intrahepatic cholestasis and can result in build-up of bile constituents in the liver with spill over into the bloodstream; other effects that patients can experience include extremely itchy skin, and because not enough bile reaches the gut, patients can have problems digesting food, which may lead to poor growth. Odevixibat is an orally administered medication that shunts bile acids away from the liver. The current study, called PEDFIC 2, suggested that odevixibat can improve the problematic signs and symptoms of progressive familial intrahepatic cholestasis and was generally safe for patients.
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Affiliation(s)
| | - Reha Artan
- Department of Pediatric Gastroenterology, Akdeniz University, Antalya, Turkey
| | - Ulrich Baumann
- Pediatric Gastroenterology and Hepatology, Hannover Medical School, Hannover, Germany
| | - Pier Luigi Calvo
- Pediatric Gastroenterology Unit, Regina Margherita Children’s Hospital, Azienda Ospedaliera-Città della Salute e della Scienza di Torino, Turin, Italy
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disorders, and Pediatrics, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Buket Dalgic
- Department of Pediatric Gastroenterology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Lorenzo D’Antiga
- Pediatric Hepatology, Gastroenterology, and Transplantation, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Angelo Di Giorgio
- Pediatric Hepatology, Gastroenterology, and Transplantation, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Özlem Durmaz
- Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Emmanuel Gonzalès
- Hépatologie et Transplantation Hépatique Pédiatriques, Centre de Référence de l’Atrésie des Voies Biliaires et des Cholestases Génétiques, FSMR FILFOIE, ERN RARE LIVER, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Hépatinov, Inserm U 1193, Paris, France
| | - Tassos Grammatikopoulos
- Institute of Liver Studies, King’s College London, London, UK
- Pediatric Liver, GI, and Nutrition Center and MowatLabs, King’s College Hospital NHS Trust, London, UK
| | - Girish Gupte
- Liver Unit and Small Bowel Transplantation, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - Winita Hardikar
- Department of Gastroenterology, Royal Children's Hospital, Melbourne, Australia
| | - Roderick H.J. Houwen
- Department of Pediatric Gastroenterology at the Wilhelmina Children’s Hospital and University Medical Center, Utrecht, The Netherlands
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada
| | - Saul J. Karpen
- Pediatrics Department, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Florence Lacaille
- Pediatric Gastroenterology-Hepatology-Nutrition Unit, Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Alain Lachaux
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfant, Service D’hépatogastoentérologie et Nutrition Pédiatrique, Lyon, France
| | - Elke Lainka
- Department of Pediatric Gastroenterology, Hepatology, and Liver Transplantation, University Children’s Hospital, Essen, Germany
| | - Kathleen M. Loomes
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Cara L. Mack
- Pediatric Gastroenterology, Hepatology, & Nutrition, Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Patrick McKiernan
- Liver Unit and Small Bowel Transplantation, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | | | - Hasan Özen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sanjay R. Rajwal
- Children’s Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds Children’s Hospital, Leeds, UK
| | | | - Eyal Shteyer
- Faculty of Medicine, Hebrew University of Jerusalem, Juliet Keidan Department of Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Etienne Sokal
- Université Catholique de Louvain, Cliniques St Luc, Brussels, Belgium
| | - Ronald J. Sokol
- University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO, USA
| | - Nisreen Soufi
- Pediatrics Department, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Ekkehard Sturm
- Pediatric Gastroenterology and Hepatology, University Children’s Hospital Tübingen, Tübingen, Germany
| | - Mary Elizabeth Tessier
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine/Texas Children’s Hospital, Houston, TX, USA
| | - Wendy L. van der Woerd
- Department of Pediatric Gastroenterology at the Wilhelmina Children’s Hospital and University Medical Center, Utrecht, The Netherlands
| | - Henkjan J. Verkade
- Department of Pediatrics, University of Groningen, Beatrix Children’s Hospital/University Medical Center Groningen, Groningen, The Netherlands
| | - Jennifer M. Vittorio
- Department of Surgery, Center for Liver Disease and Transplantation, Columbia University Medical Center, New York, NY, USA
| | | | | | - Qifeng Yu
- Albireo Pharma, Inc., Boston, MA, USA
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Kemme S, Canniff JD, Feldman AG, Garth KM, Li S, Pan Z, Sokol RJ, Weinberg A, Mack CL. Cytomegalovirus in biliary atresia is associated with increased pretransplant death, but not decreased native liver survival. Hepatol Commun 2023; 7:e0175. [PMID: 37471052 PMCID: PMC10351947 DOI: 10.1097/hc9.0000000000000175] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/09/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Biliary atresia (BA) is likely caused by a common phenotypic response to various triggers; one proposed trigger, cytomegalovirus (CMV), may lead to worse outcomes. The aim of this study was to determine the severity of disease and pretransplant outcomes of infants with BA, who have evidence of CMV (CMV+) at diagnosis compared with CMV-negative (CMV-) infants. METHODS The study used data and biospecimens from the Childhood Liver Disease Research Network PROBE study of cholestatic infants. Plasma obtained at the time of hepatic portoenterostomy (HPE) of 249 infants with BA was tested for CMV by DNA-PCR and CMV-IgM. Comparisons between CMV+ and CMV- infants were made using Wilcoxon rank sum, Student t test, chi-square, or Fisher exact test. Native liver survival (NLS) outcomes were analyzed using Kaplan-Meier and Cox regression adjusting for age at HPE; pretransplant patient survival outcomes were analyzed using a competing risk model and adjusting for age at HPE. RESULTS CMV+ infants (n = 29, 12%) underwent HPE later (67.8±13.6 d vs. 55.1±18.5 d, p = 0.0005) and had higher baseline alkaline phosphatase and aminotransferases. There was no difference between groups in jaundice clearance or NLS. The subdistribution HR of pretransplant death for CMV+ infants adjusted for age at HPE was 3.8 (p = 0.034). CONCLUSIONS CMV infection at the time of HPE in infants with BA is not associated with worse NLS despite the association with worse liver injury, older age at HPE, and increased risk of pretransplant death adjusted for age at HPE. Continued evaluation of the consequences of CMV infection and the effects of antiviral treatment should be explored.
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Affiliation(s)
- Sarah Kemme
- D.Brent Polk Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carrell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Jennifer D. Canniff
- Department of Pediatrics, Medicine, and Pathology, University of Colorado, Aurora, Colorado, USA
| | - Amy G. Feldman
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Krystle M. Garth
- Department of Pediatrics, Medicine, and Pathology, University of Colorado, Aurora, Colorado, USA
| | - Shaobing Li
- Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Zhaoxing Pan
- Department of Pediatrics, Research Institute, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ronald J. Sokol
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Adriana Weinberg
- Department of Pediatrics, Medicine, and Pathology, University of Colorado, Aurora, Colorado, USA
| | - Cara L. Mack
- Division of Pediatric Gastroenterology, Department of Pediatrics, Hepatology & Nutrition, Medical College of Wisconsin, Children’s Wisconsin, Milwaukee, Wisconsin, USA
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Harrington C, Krishnan S, Mack CL, Cravedi P, Assis DN, Levitsky J. Noninvasive biomarkers for the diagnosis and management of autoimmune hepatitis. Hepatology 2022; 76:1862-1879. [PMID: 35611859 PMCID: PMC9796683 DOI: 10.1002/hep.32591] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 01/07/2023]
Abstract
Autoimmune hepatitis (AIH) is a rare disease of unclear etiology characterized by loss of self-tolerance that can lead to liver injury, cirrhosis, and acute liver failure. First-line treatment consists of systemic corticosteroids, or budesonide, and azathioprine, to which most patients are initially responsive, although predictors of response are lacking. Relapses are very common, correlate with histological activity despite normal serum transaminases, and increase hepatic fibrosis. Furthermore, current regimens lead to adverse effects and reduced quality of life, whereas medication titration is imprecise. Biomarkers that can predict the clinical course of disease, identify patients at elevated risk for relapse, and improve monitoring and medication dosing beyond current practice would have high clinical value. Herein, we review novel candidate biomarkers in adult and pediatric AIH based on prespecified criteria, including gene expression profiles, proteins, metabolites, and immune cell phenotypes in different stages of AIH. We also discuss biomarkers relevant to AIH from other immune diseases. We conclude with proposed future directions in which biomarker implementation into clinical practice could lead to advances in personalized therapeutic management of AIH.
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Affiliation(s)
- Claire Harrington
- Division of Gastroenterology & HepatologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Swathi Krishnan
- Medicine DepartmentYale School of MedicineNew HavenConnecticutUSA
| | - Cara L. Mack
- Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital ColoradoUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Paolo Cravedi
- Division of NephrologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - David N. Assis
- Section of Digestive DiseasesYale School of MedicineNew HavenConnecticutUSA
| | - Josh Levitsky
- Division of Gastroenterology & HepatologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
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Yoeli D, Mack CL, Navarro‐Alvarez N. Role of galectin-3 in the pathogenesis and progression of biliary atresia. Clin Liver Dis (Hoboken) 2022; 20:170-174. [PMID: 36447904 PMCID: PMC9700053 DOI: 10.1002/cld.1245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/23/2022] [Accepted: 06/30/2022] [Indexed: 11/27/2022] Open
Abstract
Content available: Audio Recording.
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Affiliation(s)
- Dor Yoeli
- Division of Transplant SurgeryDepartment of SurgeryUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Cara L. Mack
- Division of Pediatric Gastroenterology, Hepatology and NutritionDepartment of PediatricsChildren's Wisconsin, Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Nalu Navarro‐Alvarez
- Division of Transplant SurgeryDepartment of SurgeryUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA,Department of GastroenterologyInstituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMexico CityMexico
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Yoeli D, Choudhury RA, Sundaram SS, Mack CL, Roach JP, Karrer FM, Wachs ME, Adams MA. Primary vs. salvage liver transplantation for biliary atresia: A retrospective cohort study. J Pediatr Surg 2022; 57:407-413. [PMID: 35065808 DOI: 10.1016/j.jpedsurg.2021.12.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/20/2021] [Accepted: 12/30/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Kasai hepatoportoenterostomy is the standard of care for children with biliary atresia, but a majority of patients progress to end-stage liver disease and require a salvage liver transplant. Given the high failure rates of the hepatoportoenterostomy operation, some have advocated for primary liver transplantation as a superior treatment approach. The aim of this study was to compare outcomes of pediatric candidates with biliary atresia listed for primary vs. salvage liver transplantation. METHODS The SRTR/OPTN database was retrospectively reviewed for all children with biliary atresia listed for liver transplant between March 2002 and February 2021. Candidates were categorized as primary liver transplant if they had not undergone previous abdominal surgery prior to listing and salvage liver transplant if they had. Salvage transplants were further categorized as early failure if listed within the first year of life or late failure if listed at an older age. RESULTS 3438 children with biliary atresia were listed for transplant during the study period, with 15% of them listed for a primary transplant, 17% for salvage transplant after early failure, and 67% after late failure. Recipients of salvage liver transplant with late failure had lower bilirubin levels and were less critically ill as demonstrated by MELD/PELD scores and hospitalization status. Correspondingly, these recipients had higher waiting list and graft survival, though this did not remain statistically significant after adjustment in multivariable models. There were no differences in waiting list, recipient, or graft survival with primary vs. salvage liver transplant after early failure. CONCLUSION Kasai hepatoportoenterostomy should remain the standard of care in biliary atresia as it may delay need for transplant beyond the first year of life in a subset of recipients and does not jeopardize subsequent transplant outcomes, even with early failure. LEVELS OF EVIDENCE Retrospective cohort study (Level III).
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Affiliation(s)
- Dor Yoeli
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA.
| | - Rashikh A Choudhury
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Shikha S Sundaram
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, The Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Cara L Mack
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, The Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Jonathan P Roach
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Frederick M Karrer
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Michael E Wachs
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Megan A Adams
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
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Mack CL. HLA Associations in pediatric autoimmune liver diseases: Current state and future research initiatives. Front Immunol 2022; 13:1019339. [DOI: 10.3389/fimmu.2022.1019339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
The strongest genetic association with autoimmunity is within chromosome 6p21, where the human leukocyte antigen (HLA) complex resides. This review will focus on the HLA associations within pediatric autoimmune hepatitis, autoimmune sclerosing cholangitis and primary sclerosing cholangitis. In general, there is considerable overlap in HLA genotypes conferring susceptibility to pediatric autoimmune liver diseases, however unique HLA associations and protective HLA genotypes exist. There are numerous areas for future research initiatives in pediatric autoimmune liver diseases and HLA associations with clinical outcomes, autoantigen discovery and novel therapeutics targeting the HLA- autoantigen- T cell pathway will be highlighted.
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Chaidez A, Pan Z, Sundaram SS, Boster J, Lovell M, Sokol RJ, Mack CL. The discriminatory ability of FibroScan liver stiffness measurement, controlled attenuation parameter, and FibroScan-aspartate aminotransferase to predict severity of liver disease in children. Hepatol Commun 2022; 6:3015-3023. [PMID: 36069338 PMCID: PMC9592794 DOI: 10.1002/hep4.1983] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/10/2022] [Indexed: 12/14/2022] Open
Abstract
Vibration controlled transient elastography (FibroScan) is used to predict the severity of liver fibrosis and steatosis. In pediatrics, few studies have been performed directly comparing liver histologic features with FibroScan liver stiffness measurements (LSMs) and controlled attenuation parameters (CAPs). The FibroScan-aspartate aminotransferase (FAST) score, which predicts liver disease severity in adult nonalcoholic fatty liver disease (NAFLD), has not been analyzed in children. The aims of this study were to determine if LSM and CAP correlated with liver histologic fibrosis stage and steatosis grade, respectively, and to determine the predictive capacity of FAST in pediatric NAFLD. Research participants (n = 216) included those with FibroScan within 90 days of a liver biopsy. The ability of LSM, CAP, and FAST to predict severity of liver disease was analyzed by Spearman correlation, linear regression, and receiver operating characteristic and C statistic. Significant correlations were identified between LSM and Ishak fibrosis stages, with the strongest correlation occurring in the non-NAFLD group (Spearman r = 0.47, p < 0.0001). LSM adequately predicted Ishak stages F0-2 versus F3-F6 (area under the receiver operating characteristic curve [AUROC], 0.73 for all; 0.77 for non-NAFLD). CAP strongly predicted histologic steatosis grade (r = 0.84; p < 0.0001; AUROC, 0.98). FAST had acceptable discriminatory ability for significant liver disease (AUROC, 0.75). A FAST cutoff ≥0.67 had a sensitivity of 89% but a specificity of only 62% at determining significant liver disease. This study encompasses one of the largest pediatric cohorts describing the accuracy of FibroScan LSM and CAP to predict liver histologic fibrosis stage and steatosis grade, respectively. In order to determine specific LSM, CAP, and FAST cut-off values for fibrosis stages, steatosis grades, and significant liver disease, respectively, a much larger cohort is necessary and will likely entail the need for multicentered studies.
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Affiliation(s)
- Alexander Chaidez
- Section of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsPediatric Liver CenterChildren's Hospital ColoradoUniversity of Colorado School of Medicine and Anschutz Medical CampusAuroraColoradoUSA
| | - Zhaoxing Pan
- Clinical and Translational Science InstituteUniversity of Colorado School of Medicine and Anschutz Medical CampusAuroraColoradoUSA
| | - Shikha S. Sundaram
- Section of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsPediatric Liver CenterChildren's Hospital ColoradoUniversity of Colorado School of Medicine and Anschutz Medical CampusAuroraColoradoUSA
| | - Julia Boster
- Section of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsPediatric Liver CenterChildren's Hospital ColoradoUniversity of Colorado School of Medicine and Anschutz Medical CampusAuroraColoradoUSA
| | - Mark Lovell
- Department of PathologyUniversity of Colorado School of Medicine and Anschutz Medical CampusAuroraColoradoUSA
| | - Ronald J. Sokol
- Section of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsPediatric Liver CenterChildren's Hospital ColoradoUniversity of Colorado School of Medicine and Anschutz Medical CampusAuroraColoradoUSA
| | - Cara L. Mack
- Section of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsPediatric Liver CenterChildren's Hospital ColoradoUniversity of Colorado School of Medicine and Anschutz Medical CampusAuroraColoradoUSA,Department of PediatricsMedical College of WisconsinChildren's Hospital WisconsinMilwaukeeWisconsinUSA
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11
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Thompson RJ, Arnell H, Artan R, Baumann U, Calvo PL, Czubkowski P, Dalgic B, D'Antiga L, Durmaz Ö, Fischler B, Gonzalès E, Grammatikopoulos T, Gupte G, Hardikar W, Houwen RHJ, Kamath BM, Karpen SJ, Kjems L, Lacaille F, Lachaux A, Lainka E, Mack CL, Mattsson JP, McKiernan P, Özen H, Rajwal SR, Roquelaure B, Shagrani M, Shteyer E, Soufi N, Sturm E, Tessier ME, Verkade HJ, Horn P. Odevixibat treatment in progressive familial intrahepatic cholestasis: a randomised, placebo-controlled, phase 3 trial. Lancet Gastroenterol Hepatol 2022; 7:830-842. [DOI: 10.1016/s2468-1253(22)00093-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/14/2022] [Accepted: 03/17/2022] [Indexed: 12/12/2022]
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12
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Boster JM, Feldman AG, Mack CL, Sokol RJ, Sundaram SS. Malnutrition in Biliary Atresia: Assessment, Management, and Outcomes. Liver Transpl 2022; 28:483-492. [PMID: 34669243 PMCID: PMC8857023 DOI: 10.1002/lt.26339] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 01/05/2023]
Abstract
Children with biliary atresia (BA), particularly infants, are at high risk for malnutrition attributed to a multitude of factors, including poor oral intake and intolerance of enteral feeding, fat malabsorption, abnormal nutrient metabolism, and increased caloric demand. Malnutrition and sarcopenia negatively impact outcomes in BA, leading to higher pretransplant and posttransplant morbidity and mortality. This review summarizes factors contributing to nutritional deficiencies in BA and offers an organized approach to the assessment and management of malnutrition in this vulnerable population.
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Affiliation(s)
- Julia M Boster
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy G Feldman
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Cara L Mack
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ronald J Sokol
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Shikha S Sundaram
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
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13
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Abstract
Content available: Audio Recording.
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Affiliation(s)
- Michelle M. Corrado
- AASLD Emerging Liver Scholar, 2020,University of Colorado School of MedicineChildren’s Hospital ColoradoAuroraCO
| | - Cara L. Mack
- University of Colorado School of MedicineChildren’s Hospital ColoradoAuroraCO,Hewit/Andrews Chair in Pediatric Liver DiseaseUniversity of ColoradoSchool of MedicineAuroraCO,Department of PediatricsSection of Pediatric GastroenterologyHepatology & Nutrition Children's Hospital ColoradoDigestive Health Institute‐Pediatric Liver CenterUniversity of Colorado School of MedicineAuroraCO
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14
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Abstract
In chronic hepatitis, a broad differential diagnosis should be considered to accurately identify the cause(s) of liver injury. Autoimmune liver diseases (autoimmune hepatitis, primary sclerosing cholangitis, overlap syndrome) can occur in the setting of limited symptoms; therefore, a high index of suspicion and appropriate diagnostic workup should be performed. Most children with autoimmune hepatitis achieve sustained remission with medical therapy; however, there are no equivalent therapies for primary sclerosing cholangitis that impact the progression of disease. Research should include biomarker studies to predict histologic remission in autoimmune hepatitis and mechanistic studies to define future treatment targets for primary sclerosing cholangitis.
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Affiliation(s)
- Sarah Kemme
- Section of Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, University of Colorado Denver School of Medicine and Children's Hospital Colorado, 13123 East 16th Avenue, Mailstop B290, Aurora, CO 80045, USA.
| | - Cara L Mack
- Section of Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, University of Colorado Denver School of Medicine and Children's Hospital Colorado, 13123 East 16th Avenue, Mailstop B290, Aurora, CO 80045, USA
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15
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Martinez M, Perito ER, Valentino P, Mack CL, Aumar M, Broderick A, Draijer LG, Fagundes ED, Furuya KN, Gupta N, Horslen S, Jonas MM, Kamath BM, Kerkar N, Kim KM, Kolho KL, Koot BGP, Laborda TJ, Lee CK, Loomes KM, Miloh T, Mogul D, Mohammed S, Ovchinsky N, Rao G, Ricciuto A, Schwarz KB, Smolka V, Tanaka A, Tessier MEM, Venkat VL, Vitola BE, Woynarowski M, Zerofsky M, Deneau MR, Deneau MR. Recurrence of Primary Sclerosing Cholangitis After Liver Transplant in Children: An International Observational Study. Hepatology 2021; 74:2047-2057. [PMID: 34008252 PMCID: PMC8530456 DOI: 10.1002/hep.31911] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Recurrent primary sclerosing cholangitis (rPSC) following liver transplant (LT) has a negative impact on graft and patient survival; little is known about risk factors for rPSC or disease course in children. APPROACH AND RESULTS We retrospectively evaluated risk factors for rPSC in 140 children from the Pediatric PSC Consortium, a multicenter international registry. Recipients underwent LT for PSC and had >90 days of follow-up. The primary outcome, rPSC, was defined using Graziadei criteria. Median follow-up after LT was 3 years (interquartile range 1.1-6.1). rPSC occurred in 36 children, representing 10% and 27% of the subjects at 2 years and 5 years following LT, respectively. Subjects with rPSC were younger at LT (12.9 vs. 16.2 years), had faster progression from PSC diagnosis to LT (2.5 vs. 4.1 years), and had higher alanine aminotransferase (112 vs. 66 IU/L) at LT (all P < 0.01). Inflammatory bowel disease was more prevalent in the rPSC group (86% vs. 66%; P = 0.025). After LT, rPSC subjects had more episodes of biopsy-proved acute rejection (mean 3 vs. 1; P < 0.001), and higher prevalence of steroid-refractory rejection (41% vs. 20%; P = 0.04). In those with rPSC, 43% developed complications of portal hypertension, were relisted for LT, or died within 2 years of the diagnosis. Mortality was higher in the rPSC group (11.1% vs. 2.9%; P = 0.05). CONCLUSIONS The incidence of rPSC in this cohort was higher than previously reported, and was associated with increased morbidity and mortality. Patients with rPSC appeared to have a more aggressive, immune-reactive phenotype. These findings underscore the need to understand the immune mechanisms of rPSC, to lay the foundation for developing new therapies and improve outcomes in this challenging population.
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Affiliation(s)
| | | | | | - Cara L Mack
- University of Colorado School of Medicine, Aurora, CO
| | | | - Annemarie Broderick
- Children’s Health Ireland at Crumlin & University College Dublin, Dublin, Ireland
| | | | | | - Katryn N. Furuya
- Mayo Clinic, Rochester, MN and Medical College of Wisconsin, Milwaukee, WI
| | - Nitika Gupta
- Emory University School of Medicine, Atlanta, GA
| | | | - Maureen M Jonas
- Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | | | - Nanda Kerkar
- University of Rochester Medical Center, Rochester, NY
| | | | - Kaija-Leena Kolho
- University of Helsinki Hospital and Tampere University, Helsinki, Finland
| | - Bart GP Koot
- Amsterdam University Medical Center Amsterdam, The Netherlands
| | - Trevor J Laborda
- University of Utah and Intermountain Primary Children’s Hospital, Salt Lake City, UT
| | | | | | | | | | | | - Nadia Ovchinsky
- Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | | | | | - Kathleen B Schwarz
- University of California San Diego, San Diego, CA and Johns Hopkins University, Baltimore, MD
| | | | | | | | | | | | - Marek Woynarowski
- Faculty of Medicine and Health Sciences, UJK Kielce, Poland (former IP CZD Warsaw)
| | | | - Mark R. Deneau
- University of Utah and Intermountain Primary Children’s Hospital, Salt Lake City, UT
| | - Mark R. Deneau
- Department of Pediatrics University of Utah and Intermountain Primary Children’s Hospital Salt Lake City UT
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16
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Luo Y, Brigham D, Bednarek J, Torres R, Wang D, Ahmad S, Mack CL. Unique Cholangiocyte-Targeted IgM Autoantibodies Correlate With Poor Outcome in Biliary Atresia. Hepatology 2021; 73:1855-1867. [PMID: 32767570 PMCID: PMC7867668 DOI: 10.1002/hep.31504] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 06/27/2020] [Accepted: 07/12/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The etiology of biliary atresia (BA) is not known and is likely multifactorial, including a genetic predisposition, a viral or environmental trigger, an aberrant autoimmune response targeting cholangiocytes, and unique susceptibilities of the neonatal bile ducts to injury. Damaged cholangiocytes may express neo self-antigens and elicit autoreactive T-cell-mediated inflammation and B-cell production of autoantibodies. The aim of this study was to discover autoantibodies in BA that correlated with outcomes. APPROACH AND RESULTS An autoantigen microarray encompassing approximately 9,500 autoantigens was used to screen for serum immunoglobulin M (IgM) and immunoglobulin G (IgG) autoantibodies in patients with BA or other liver disease controls. Validation of candidate autoantibodies by enzyme-linked immunosorbent assay on a second cohort of subjects (6-12 months following Kasai portoenterostomy) and correlations of autoantibodies with outcomes were performed (serum bilirubin levels and need for liver transplant in first 2 years of life). Mean anti-chitinase 3-like 1 (CHI3L1), anti-delta-like ligand (DLL-4), and antisurfactant protein D (SFTPD) IgM autoantibodies in BA were significantly higher compared with controls, and IgM autoantibody levels positively correlated with worse outcomes. Immunofluorescence revealed cholangiocyte-predominant expression of CHI3L1, DLL-4, and SFTPD. The humoral autoantibody response was associated with C3d complement activation and T-cell autoimmunity, based on detection of cholangiocyte-predominant C3d co-staining and peripheral blood autoreactive T cells specific to CHI3L1, DLL-4 and SFTPD, respectively. CONCLUSIONS BA is associated with cholangiocyte-predominant IgM autoantibodies in the first year after Kasai portoenterostomy. Anti-CHI3L1, anti-DLL-4, and anti-SFTPD IgM autoantibody correlations with worse outcomes and the detection of C3d on cholangioctyes and antigen-specific autoreactive T cells suggest that autoimmunity plays a role in the ongoing bile duct injury and progression of disease.
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Affiliation(s)
- Yuhuan Luo
- University of Colorado School of Medicine
| | | | - Joseph Bednarek
- University of Colorado School of Medicine and University of Utah
| | | | - Dong Wang
- University of Colorado School of Medicine
| | - Sara Ahmad
- University of Colorado School of Medicine
| | - Cara L. Mack
- University of Colorado School of Medicine, Children’s Hospital Colorado
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17
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Venkat V, Ng VL, Magee JC, Ye W, Hawthorne K, Harpavat S, Molleston JP, Murray KF, Wang KS, Soufi N, Bass LM, Alonso EM, Bezerra JA, Jensen MK, Kamath BM, Loomes KM, Mack CL, Rosenthal P, Shneider BL, Squires RH, Sokol RJ, Karpen SJ. Modeling Outcomes in Children With Biliary Atresia With Native Liver After 2 Years of Age. Hepatol Commun 2020; 4:1824-1834. [PMID: 33305153 PMCID: PMC7706301 DOI: 10.1002/hep4.1602] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/21/2020] [Accepted: 07/31/2020] [Indexed: 12/15/2022] Open
Abstract
Approximately 50% of infants with biliary atresia (BA) undergoing Kasai portoenterostomy show survival with native liver (SNL) at age 2 years. Predictors of disease progression after age 2 years are unknown, despite estimates of 20%-30% undergoing liver transplant (LT) between age 2 and 18 years. We sought to address this knowledge gap by developing prognostic models in participants of the multicenter prospective National Institutes of Health-supported Childhood Liver Disease Research Network. We extracted 14 clinical and biochemical variables at age 2 years to develop two models for future outcomes: 1) LT or death (LTD) and 2) first sentinel event (SE), either new onset ascites, hepatopulmonary syndrome (HPS), or gastrointestinal (GI) bleed. A total of 240 participants, enrolled between 2004 and 2017, were followed until a median age of 5.1 years (range, 2.0-13.3 years). Of these participants, 38 underwent LT (n = 37) or death (n = 1); cumulative incidence, 23.7% (95% confidence interval [CI], 16.2%-32.0%). Twenty-seven experienced either new-onset ascites (n = 13), HPS (n = 1), or GI bleed (n = 14). One participant had ascites and GI bleed concurrently; cumulative incidence, 21.5% (95% CI, 14.2%-29.8%) by age 10 years. The Cox proportional hazard model predicted risk of LTD, using total bilirubin, albumin, platelet count, and history of either ascites or cholangitis (BA LTD model), with a C-index of 0.88 (range, 0.86-0.89). A cause-specific hazard competing risk model predicted SE using platelet count and gamma glutamyltransferase levels (BA SE model) with a C-index of 0.81 (range, 0.80-0.84). Internal model validity was assessed using Harrell's C-index with cross-validation. Conclusion: Stratification using these models identified risk of poor outcomes in patients with BA SNL after age 2 years. The models may identify those who would benefit from enhanced clinical surveillance and prioritization in clinical trials.
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Affiliation(s)
- Veena Venkat
- UPMC Children's Hospital of Pittsburgh Pittsburgh PA
| | - Vicky L Ng
- Hospital for Sick Children University of Toronto Toronto Canada
| | - John C Magee
- University of Michigan Hospitals and Health Centers Ann Arbor MI
| | - Wen Ye
- University of Michigan Hospitals and Health Centers Ann Arbor MI
| | | | - Sanjiv Harpavat
- Texas Children's Hospital Liver Center, Baylor College of Medicine Houston TX
| | | | | | | | | | - Lee M Bass
- Ann & Robert H. Lurie Children's Hospital of Chicago Chicago IL
| | | | | | - M Kyle Jensen
- University of Utah School of Medicine Primary Children's Hospital Salt Lake City UT
| | - Binita M Kamath
- Hospital for Sick Children University of Toronto Toronto Canada
| | | | - Cara L Mack
- University of Colorado School of Medicine Children's Hospital Colorado Aurora CO
| | | | - Benjamin L Shneider
- Texas Children's Hospital Liver Center, Baylor College of Medicine Houston TX
| | | | - Ronald J Sokol
- University of Colorado School of Medicine Children's Hospital Colorado Aurora CO
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18
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Feldman AG, Parsons JA, Dutmer CM, Veerapandiyan A, Hafberg E, Maloney N, Mack CL. Subacute Liver Failure Following Gene Replacement Therapy for Spinal Muscular Atrophy Type 1. J Pediatr 2020; 225:252-258.e1. [PMID: 32473148 PMCID: PMC10152980 DOI: 10.1016/j.jpeds.2020.05.044] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023]
Abstract
Spinal muscular atrophy is a neurodegenerative disease resulting from irreversible loss of anterior horn cells owing to biallelic deletions/mutations in the survival motor neuron (SMN) 1 gene. Gene replacement therapy using an adeno-associated virus vector containing the SMN gene was approved by the US Food and Drug Administration in May 2019. We report 2 cases of transient, drug-induced liver failure after this therapy.
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Affiliation(s)
- Amy G Feldman
- Children's Hospital Colorado, University of Colorado School of Medicine, Denver; Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO.
| | - Julie A Parsons
- Children's Hospital Colorado, University of Colorado School of Medicine, Denver; Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Cullen M Dutmer
- Children's Hospital Colorado, University of Colorado School of Medicine, Denver; Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | | | - Einar Hafberg
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Nolan Maloney
- University of Colorado School of Medicine, Aurora, CO
| | - Cara L Mack
- Children's Hospital Colorado, University of Colorado School of Medicine, Denver; Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
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19
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Mack CL, Adams D, Assis DN, Kerkar N, Manns MP, Mayo MJ, Vierling JM, Alsawas M, Murad MH, Czaja AJ. Diagnosis and Management of Autoimmune Hepatitis in Adults and Children: 2019 Practice Guidance and Guidelines From the American Association for the Study of Liver Diseases. Hepatology 2020; 72:671-722. [PMID: 31863477 DOI: 10.1002/hep.31065] [Citation(s) in RCA: 405] [Impact Index Per Article: 101.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Cara L Mack
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - David Adams
- Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - David N Assis
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Nanda Kerkar
- Golisano Children's Hospital at Strong, University of Rochester Medical Center, New York, NY
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Marlyn J Mayo
- Division of Digestive and Liver Diseases, University of Texas SW Medical Center, Dallas, TX
| | - John M Vierling
- Medicine and Surgery, Baylor College of Medicine, Houston, TX
| | | | - Mohammad H Murad
- Mayo Knowledge and Encounter Research Unit, Mayo Clinic College of Medicine, Rochester, MN
| | - Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
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20
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Vierling JM, Kerkar N, Czaja AJ, Mack CL, Adams D, Assis DN, Manns MP, Mayo MJ, Nayfeh T, Majzoub AMM, Alzuabi MA, Ding J, Haffar S, Murad MH, Alsawas M. Immunosuppressive Treatment Regimens in Autoimmune Hepatitis: Systematic Reviews and Meta-Analyses Supporting American Association for the Study of Liver Diseases Guidelines. Hepatology 2020; 72:753-769. [PMID: 32500593 DOI: 10.1002/hep.31407] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/30/2020] [Accepted: 05/26/2020] [Indexed: 12/13/2022]
Affiliation(s)
- John M Vierling
- Departments of Medicine and Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Nanda Kerkar
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Cara L Mack
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - David Adams
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - David N Assis
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Marlyn J Mayo
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tarek Nayfeh
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | | | - Muayad A Alzuabi
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | - Jingyi Ding
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | - Samir Haffar
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
| | - Mouaz Alsawas
- Mayo Clinic Evidence-Based Practice Research Program, Rochester, MN, USA
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21
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Kamath BM, Spino C, McLain R, Magee JC, Fredericks EM, Setchell KD, Miethke A, Molleston JP, Mack CL, Squires RH, Alonso EM, Murray KF, Loomes KM, Kyle Jensen M, Karpen SJ, Rosenthal P, Thomas D, Sokol RJ, Shneider BL. Unraveling the Relationship Between Itching, Scratch Scales, and Biomarkers in Children With Alagille Syndrome. Hepatol Commun 2020; 4:1012-1018. [PMID: 32626833 PMCID: PMC7327199 DOI: 10.1002/hep4.1522] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/12/2020] [Accepted: 02/15/2020] [Indexed: 11/21/2022] Open
Abstract
Pruritus is a debilitating symptom for patients with Alagille syndrome (ALGS). In a previously reported trial of maralixibat, an investigational antipruritic agent, itching was assessed using a digital diary based on twice‐daily caregiver observation of itching severity (Itch Reported Outcome, ItchRO[Observer]). The goal of this study was to characterize pruritus in participants with ALGS at baseline in this trial, as assessed by the ItchRO instrument and the physician‐observed clinician scratch scale (CSS), relative to biomarkers putatively associated with pruritus and health‐related quality of life assessment. Thirty‐seven participants with ALGS (median age of 6 years; range 1‐17 years) were enrolled. No association was identified between CSS and ItchRO(Obs) (r = 0.22, P = 0.2). Neither CSS nor ItchRO were associated with serum bile acids (r = −0.08, P = 0.6 for both) or autotaxin (r = 0.22, P = 0.2; r = 0.28, P = 0.12). There was no significant association between Pediatric Quality of Life Inventory total parent scores and CSS or ItchRO (r = −0.23, P = 0.2; r = −0.16, P = 0.36). There was a significant association between ItchRO and Multidimensional Fatigue Scale and Family Impact Module total scores (Pearson correlation coefficient −0.575, P = 0.0005; 0.504, P = 0.002). In exploratory analysis, selected questions relating to fatigue and sleep disturbance (n = 12) from Pediatric Quality of Life Inventory, Multidimensional Fatigue Scale, and Family Impact Module were correlated with pruritus scores; positive associations were identified. Conclusion: Itching scores did not correlate with each other, nor with putative serum biomarkers of pruritus, and further, did not correlate with quality of life. Hypothesis‐generating analyses implicate sleep disturbance and fatigue as key associations with caregiver observations of itching. This is highly relevant to the selection of surrogate endpoints for clinical trials of pruritus therapies.
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Affiliation(s)
- Binita M Kamath
- The Hospital for Sick Children University of Toronto Toronto ON Canada
| | - Cathie Spino
- School of Public Health University of Michigan Ann Arbor MI
| | - Richard McLain
- School of Public Health University of Michigan Ann Arbor MI
| | | | - Emily M Fredericks
- Child Health Evaluation and Research (CHEAR) Center University of Michigan Ann Arbor MI
| | | | | | | | - Cara L Mack
- Children's Hospital Colorado University of Colorado School of Medicine Aurora CO
| | | | - Estella M Alonso
- Ann and Robert H. Lurie Children's Hospital Northwestern University Chicago IL
| | - Karen F Murray
- Seattle Children's Hospital University of Washington School of Medicine Seattle WA
| | - Kathleen M Loomes
- The Children's Hospital of Philadelphia Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - M Kyle Jensen
- Primary Children's Hospital University of Utah Salt Lake UT
| | - Saul J Karpen
- Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | | | | | - Ronald J Sokol
- Children's Hospital Colorado University of Colorado School of Medicine Aurora CO
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22
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Goldberg A, Mack CL. Inherited Cholestatic Diseases in the Era of Personalized Medicine. Clin Liver Dis (Hoboken) 2020; 15:105-109. [PMID: 32257121 PMCID: PMC7128029 DOI: 10.1002/cld.872] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 07/21/2019] [Indexed: 02/04/2023] Open
Abstract
http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-3-reading-mack a video presentation of this article.
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Affiliation(s)
- Alyssa Goldberg
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology & NutritionChildren's Hospital Colorado, Digestive Health Institute–Pediatric Liver Center, University of Colorado School of MedicineAuroraCO
| | - Cara L. Mack
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology & NutritionChildren's Hospital Colorado, Digestive Health Institute–Pediatric Liver Center, University of Colorado School of MedicineAuroraCO,Hewit/Andrews Chair in Pediatric Liver DiseasesUniversity of Colorado School of MedicineAuroraCO
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23
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Kamath BM, Ye W, Goodrich NP, Loomes KM, Romero R, Heubi JE, Leung DH, Spinner NB, Piccoli DA, Alonso EM, Guthery SL, Karpen SJ, Mack CL, Molleston JP, Murray KF, Rosenthal P, Squires JE, Teckman J, Wang KS, Thompson R, Magee JC, Sokol RJ. Outcomes of Childhood Cholestasis in Alagille Syndrome: Results of a Multicenter Observational Study. Hepatol Commun 2020; 4:387-398. [PMID: 33313463 PMCID: PMC7049675 DOI: 10.1002/hep4.1468] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/19/2019] [Indexed: 01/04/2023] Open
Abstract
Alagille syndrome (ALGS) is an autosomal dominant multisystem disorder with cholestasis as a defining clinical feature. We sought to characterize hepatic outcomes in a molecularly defined cohort of children with ALGS‐related cholestasis. Two hundred and ninety‐three participants with ALGS with native liver were enrolled. Participants entered the study at different ages and data were collected retrospectively prior to enrollment, and prospectively during the study course. Genetic analysis in 206 revealed JAGGED1 mutations in 91% and NOTCH2 mutations in 4%. Growth was impaired with mean height and weight z‐scores of <−1.0 at all ages. Regression analysis revealed that every 10 mg/dL increase in total bilirubin was associated with a decrease in height z‐score by 0.10 (P = 0.03) and weight z‐score by 0.15 (P = 0.007). Total bilirubin was higher for younger participants (P = 0.03) with a median of 6.9 mg/dL for those less than 1 year old compared with a median of 1.3 mg/dL for participants 13 years or older. The median gamma glutamyl transferase also dropped from 612 to 268 in the same age groups. After adjusting for age, there was substantial within‐individual variation of alanine aminotransferase. By 20 years of age, 40% of participants had developed definite portal hypertension. Estimated liver transplant–free survival at the age of 18.5 years was 24%. Conclusions: This is the largest multicenter natural history study of cholestasis in ALGS, demonstrating a previously underappreciated burden of liver disease with early profound cholestasis, a second wave of portal hypertension later in childhood, and less than 25% of patients reaching young adulthood with their native liver. These findings will promote optimization of ALGS management and development of clinically relevant endpoints for future therapeutic trials.
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Affiliation(s)
- Binita M Kamath
- The Hospital for Sick Children University of Toronto Toronto ON Canada
| | - Wen Ye
- Department of Surgery University of Michigan Ann Arbor MI
| | | | - Kathleen M Loomes
- The Children's Hospital of Philadelphia Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Rene Romero
- Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | - James E Heubi
- Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Daniel H Leung
- Baylor College of Medicine Texas Children's Hospital Houston TX
| | - Nancy B Spinner
- The Children's Hospital of Philadelphia Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - David A Piccoli
- The Children's Hospital of Philadelphia Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Estella M Alonso
- Ann and Robert H. Lurie Children's Hospital Northwestern University Chicago IL
| | | | - Saul J Karpen
- Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | - Cara L Mack
- University of Colorado School of Medicine Children's Hospital Colorado Aurora CO
| | | | - Karen F Murray
- Seattle Children's Hospital University of Washington School of Medicine Seattle WA
| | - Philip Rosenthal
- Department of Pediatrics University of California, San Francisco San Francisco CA
| | - James E Squires
- Department of Gastroenterology and Hepatology UPMC Children's Hospital of Pittsburgh Pittsburgh PA
| | - Jeffrey Teckman
- Department of Pediatrics Saint Louis University School of Medicine St. Louis MO
| | - Kasper S Wang
- Department of Surgery Children's Hospital Los Angeles Los Angeles CA
| | - Richard Thompson
- Institute of Liver Studies King's College London London United Kingdom
| | - John C Magee
- Department of Surgery University of Michigan Ann Arbor MI
| | - Ronald J Sokol
- University of Colorado School of Medicine Children's Hospital Colorado Aurora CO
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Abstract
Autoreactive B cells can promote autoimmunity through antigen presentation to autoreactive T cells, production of autoantibodies, generation of cytokines promoting T cell activation and differentiation, and inhibition of regulatory T cells and B cells. Here, the authors highlight studies pertaining to B cell mechanisms associated with disease pathogenesis and outcomes in autoimmune hepatitis and the immune-mediated cholangiopathies (primary biliary cholangitis, primary sclerosing cholangitis, and biliary atresia). The vast majority of investigations focus on autoantibodies and future research endeavors should include deciphering the role of the B cell in T cell activation (through antigen presentation, cytokine/chemokine production, and inhibition of regulation). Targeting B cell mechanisms in the treatment of autoimmune liver diseases is also highlighted.
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Affiliation(s)
- Sarah A. Taylor
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - David N. Assis
- Section of Digestive Diseases, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Cara L. Mack
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Digestive Health Institute, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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25
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Kim S, Moore J, Alonso E, Bednarek J, Bezerra JA, Goodhue C, Karpen SJ, Loomes KM, Magee JC, Ng VL, Sherker AH, Smith C, Spino C, Venkat V, Wang K, Sokol RJ, Mack CL. Correlation of Immune Markers With Outcomes in Biliary Atresia Following Intravenous Immunoglobulin Therapy. Hepatol Commun 2019; 3:685-696. [PMID: 31061956 PMCID: PMC6492477 DOI: 10.1002/hep4.1332] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/11/2019] [Indexed: 12/13/2022] Open
Abstract
Biliary atresia is a progressive fibroinflammatory cholangiopathy of infancy that is associated with activation of innate and adaptive immune responses targeting bile ducts. A recently completed multicenter phase I/IIA trial of intravenous immunoglobulin in biliary atresia did not improve serum total bilirubin levels at 90 days after hepatoportoenterostomy or survival with the native liver at 1 year. A mechanistic aim of this trial was to determine if the peripheral blood immunophenotype was associated with clinical outcomes. Flow cytometry of peripheral blood cell markers (natural killer [NK], macrophage subsets, T‐ and B‐cell subsets, regulatory T cells), neutrophils, and activation markers (clusters of differentiation [CD]38, CD69, CD86, human leukocyte antigen‐DR isotype [HLA‐DR]) was performed on 29 patients with biliary atresia at baseline and at 60, 90, 180, and 360 days after hepatoportoenterostomy. Plasma cytokines and neutrophil products were also measured. Spearman correlations of change of an immune marker from baseline to day 90 with change in serum bilirubin revealed that an increase in total bilirubin correlated with 1) increased percentage of HLA‐DR+CD38+ NK cells and expression of NK cell activation markers CD69 and HLA‐DR, 2) decreased percentage of regulatory T cells, and 3) increased interleukin (IL)‐8 and associated neutrophil products (elastase and neutrophil extracellular traps). Cox modeling revealed that the change from baseline to day 60 of the percentage of HLA‐DR+CD38+ NK cells and plasma IL‐8 levels was associated with an increased risk of transplant or death by day 360. Conclusion: Poor outcomes in biliary atresia correlated with higher peripheral blood NK cells and IL‐8 and lower regulatory T cells. Future studies should include immunotherapies targeting these pathways in order to protect the biliary tree from ongoing damage.
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Affiliation(s)
| | | | - Estella Alonso
- Ann and Robert H. Lurie Children's Hospital of Chicago Chicago IL
| | | | | | | | | | | | | | - Vicky L Ng
- The Hospital for Sick Children, University of Toronto Toronto Canada
| | - Averell H Sherker
- National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases Bethesda MD
| | | | | | | | - Kasper Wang
- Children's Hospital Los Angeles Los Angeles CA
| | - Ronald J Sokol
- Children's Hospital Colorado, University of Colorado School of Medicine Aurora CO
| | - Cara L Mack
- Children's Hospital Colorado, University of Colorado School of Medicine Aurora CO
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26
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Alonso EM, Ye W, Hawthorne K, Venkat V, Loomes KM, Mack CL, Hertel PM, Karpen SJ, Kerkar N, Molleston JP, Murray KF, Romero R, Rosenthal P, Schwarz KB, Shneider BL, Suchy FJ, Turmelle YP, Wang KS, Sherker AH, Sokol RJ, Bezerra JA, Magee JC. Impact of Steroid Therapy on Early Growth in Infants with Biliary Atresia: The Multicenter Steroids in Biliary Atresia Randomized Trial. J Pediatr 2018; 202:179-185.e4. [PMID: 30244988 PMCID: PMC6365098 DOI: 10.1016/j.jpeds.2018.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/06/2018] [Accepted: 07/02/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To investigate the impact of corticosteroid therapy on the growth of participants in the Steroids in Biliary Atresia Randomized Trial (START) conducted through the Childhood Liver Disease Research Network. The primary analysis in START indicated that steroids did not have a beneficial effect on drainage in a cohort of infants with biliary atresia. We hypothesized that steroids would have a detrimental effect on growth in these infants. STUDY DESIGN A total of 140 infants were enrolled in START, with 70 randomized to each treatment arm: steroid and placebo. Length, weight, and head circumference were obtained at baseline and follow-up visits to 24 months of age. RESULTS Patients treated with steroids had significantly lower length and head circumference z scores during the first 3 months post-hepatoportoenterostomy (HPE), and significantly lower weight until 12 months. Growth trajectories in the steroid and placebo arms differed significantly for length (P < .0001), weight (P = .009), and head circumference (P < .0001) with the largest impact noted for those with successful HPE. Growth trajectory for head circumference was significantly lower in patients treated with steroids irrespective of HPE status, but recovered during the second 6 months of life. CONCLUSIONS Steroid therapy following HPE in patients with biliary atresia is associated with impaired length, weight, and head circumference growth trajectories for at least 6 months post-HPE, especially impacting infants with successful bile drainage. TRIAL REGISTRATION ClinicalTrials.gov: NCT00294684.
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Affiliation(s)
- Estella M Alonso
- Division of Gastroenterology, Hepatology, and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Wen Ye
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | | | - Veena Venkat
- Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Cara L Mack
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Paula M Hertel
- Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Houston, TX
| | - Saul J Karpen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA
| | - Nanda Kerkar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA; Division of Pediatric Gastroenterology, The Mount Sinai School of Medicine, New York, NY
| | - Jean P Molleston
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, Rylie Hospital for Children, Indianapolis, IN
| | - Karen F Murray
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington and Seattle Children's, Seattle, WA
| | - Rene Romero
- Pediatrics, Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, San Francisco, CA
| | | | - Benjamin L Shneider
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Frederick J Suchy
- Children's Hospital Research Institute, Children's Hospital Colorado, Aurora, CO
| | | | - Kasper S Wang
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Averell H Sherker
- Liver Diseases Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Ronald J Sokol
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Jorge A Bezerra
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - John C Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
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27
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Bednarek J, Traxinger B, Brigham D, Roach J, Orlicky D, Wang D, Pelanda R, Mack CL. Cytokine-Producing B Cells Promote Immune-Mediated Bile Duct Injury in Murine Biliary Atresia. Hepatology 2018; 68:1890-1904. [PMID: 29679373 PMCID: PMC6195851 DOI: 10.1002/hep.30051] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 04/02/2018] [Accepted: 04/14/2018] [Indexed: 12/13/2022]
Abstract
Biliary atresia (BA) is a neonatal T cell-mediated, inflammatory, sclerosing cholangiopathy. In the rhesus rotavirus (RRV)-induced neonatal mouse model of BA (murine BA), mice lacking B cells do not develop BA, and the lack of B cells is associated with loss of T-cell and macrophage activation. The aim of this study was to determine the mechanism of B cell-mediated immune activation (antigen presentation versus cytokine production) in murine BA. Normal neonatal B cells in the liver are predominantly at pro-B and pre-B cellular development. However, BA mice exhibit a significant increase in the number and activation status of mature liver B cells. Adoptively transferred B cells into RRV-infected, B cell-deficient mice were able to reinstate T-cell and macrophage infiltration and biliary injury. Nonetheless, neonatal liver B cells were incompetent at antigen presentation to T cells. Moreover, 3-83 immunoglobulin transgenic mice, in which B cells only present an irrelevant antigen, developed BA, indicating a B-cell antigen-independent mechanism. B cells from BA mice produced a variety of innate and adaptive immune cytokines associated with immune activation. In vitro trans-well studies revealed that BA B cells secreted cytokines that activated T cells based on increased expression of T-cell activation marker cluster of differentiation 69. Conclusion: Neonatal liver B cells are highly activated in murine BA and contribute to immune activation through production of numerous cytokines involved in innate and adaptive immunity; this work provides increased knowledge on the capacity of neonatal B cells to contribute to an inflammatory disease through cytokine-mediated mechanisms, and future studies should focus on targeting B cells as a therapeutic intervention in human BA.
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Affiliation(s)
- Joseph Bednarek
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine
| | - Brianna Traxinger
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine
| | - Dania Brigham
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine
| | - Jonathan Roach
- Department of Surgery, University of Colorado School of Medicine
| | - David Orlicky
- Department of Pathology, University of Colorado School of Medicine
| | - Dong Wang
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine
| | - Roberta Pelanda
- Department of Immunology and Microbiology, University of Colorado School of Medicine
| | - Cara L. Mack
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine
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28
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Shneider BL, Spino C, Kamath BM, Magee JC, Bass LM, Setchell KD, Miethke A, Molleston JP, Mack CL, Squires RH, Murray KF, Loomes KM, Rosenthal P, Karpen SJ, Leung DH, Guthery SL, Thomas D, Sherker AH, Sokol RJ. Placebo-Controlled Randomized Trial of an Intestinal Bile Salt Transport Inhibitor for Pruritus in Alagille Syndrome. Hepatol Commun 2018; 2:1184-1198. [PMID: 30288474 PMCID: PMC6167076 DOI: 10.1002/hep4.1244] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/13/2018] [Indexed: 01/06/2023] Open
Abstract
Medically refractory, severe, cholestasis-induced pruritus in Alagille syndrome may be improved by surgical interruption of the enterohepatic circulation. This multicenter trial (NCT02057692) tested the hypothesis that the intestinal bile acid transport inhibitor maralixibat would similarly reduce pruritus in Alagille syndrome. Thirty-seven children with Alagille syndrome were randomly assigned to double-blinded administration of placebo, 70, 140, or 280 µg/kg/day of maralixibat for 13 weeks. Pruritus was assessed by caregiver (itch-reported outcome instrument [ItchRO]) and clinician report (range, 0-4 [severe]). Liver chemistries and serum bile acids were measured. The primary outcome was the change from baseline to week 13 in ItchRO relative to placebo. In the a priori first analysis of the primary efficacy endpoint, the mean adjusted difference between participants receiving 140 or 280 µg/kg/day and placebo was -0.47 (95% confidence interval [CI], -1.14, 0.20; P = 0.16). Statistically significant decreases were observed with doses of 70 and 140 µg/kg/day (mean adjusted difference, -0.89; 95% CI, -1.70, -0.08; P = 0.032; and mean adjusted difference, -0.91; 95% CI, -1.62, -0.19; P = 0.014) but not 280 µg/kg/day (mean adjusted difference, -0.04; 95% CI, -0.94, 0.86; P = 0.44) or all doses combined (mean adjusted difference, -0.61; 95% CI, -1.24, 0.20; P = 0.055). A 1-point reduction in pruritus was more common in maralixibat-treated versus placebo-treated participants (caregiver ItchRO, 65% versus 25%; P = 0.06; clinician score, 76% versus 25%; P = 0.01). There were no significant changes in liver chemistries or bile acids relative to placebo. Adverse and serious adverse events were similar between maralixibat and placebo. Conclusion: Although the prespecified primary analyses of ItchRO were not all statistically significant, the data suggest that maralixibat is safe and may reduce pruritus in Alagille syndrome.
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Affiliation(s)
- Benjamin L. Shneider
- Section of Pediatric Gastroenterology, Hepatology, and NutritionBaylor College of MedicineHoustonTX
| | - Cathie Spino
- School of Public HealthUniversity of MichiganAnn ArborMI
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick ChildrenUniversity of TorontoTorontoCanada
| | | | - Lee M. Bass
- Pediatrics Division of Gastroenterology, Hepatology, and NutritionAnn and Robert H. Lurie Children’s Hospital of ChicagoChicagoIL
| | - Kenneth D. Setchell
- Department of Pediatrics‐PathologyCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Alexander Miethke
- Division of Pediatric Gastroenterology, Hepatology, and NutritionCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Jean P. Molleston
- Division of Pediatric Gastroenterology, Hepatology, and NutritionIndiana University School of Medicine/Riley Hospital for ChildrenIndianapolisIN
| | - Cara L. Mack
- Section of Pediatric Gastroenterology, Hepatology, and NutritionChildren's Hospital ColoradoAuroraCO
| | | | - Karen F. Murray
- Division of Gastroenterology and HepatologyUniversity of Washington School of Medicine, Seattle Children’s HospitalSeattleWA
| | - Kathleen M. Loomes
- Pediatric Gastroenterology, Hepatology, and NutritionChildren’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of PediatricsUniversity of California San FranciscoSan FranciscoCA
| | - Saul J. Karpen
- Pediatric Gastroenterology, Hepatology, and NutritionEmory University School of Medicine/Children’s Healthcare of AtlantaAtlantaGA
| | - Daniel H. Leung
- Section of Pediatric Gastroenterology, Hepatology, and NutritionBaylor College of MedicineHoustonTX
| | - Stephen L. Guthery
- Pediatric Gastroenterology, Hepatology, and NutritionUniversity of UtahSalt Lake CityUT
| | - Danny Thomas
- Department of GastroenterologyChildren's Hospital Los AngelesLos AngelesCA
| | - Averell H. Sherker
- Liver Diseases Research Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
| | - Ronald J. Sokol
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of PediatricsUniversity of Colorado School of MedicineAuroraCO
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29
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Bezerra JA, Wells RG, Mack CL, Karpen SJ, Hoofnagle J, Doo E, Sokol RJ. Biliary Atresia: Clinical and Research Challenges for the Twenty-First Century. Hepatology 2018; 68:1163-1173. [PMID: 29604222 PMCID: PMC6167205 DOI: 10.1002/hep.29905] [Citation(s) in RCA: 172] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 03/08/2018] [Accepted: 03/27/2018] [Indexed: 12/12/2022]
Abstract
Biliary atresia (BA) is a fibroinflammatory disease of the intrahepatic and extrahepatic biliary tree. Surgical hepatic portoenterostomy (HPE) may restore bile drainage, but progression of the intrahepatic disease results in complications of portal hypertension and advanced cirrhosis in most children. Recognizing that further progress in the field is unlikely without a better understanding of the underlying cause(s) and pathogenesis of the disease, the National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK) sponsored a research workshop focused on innovative and promising approaches and on identifying future areas of research. Investigators discussed recent advances using gestational ultrasound and results of newborn BA screening with serum direct (conjugated) bilirubin that support a prenatal onset of biliary injury. Experimental and human studies implicate the toxic properties of environmental toxins (e.g., biliatresone) and of viruses (e.g., cytomegalovirus) to the biliary system. Among host factors, sequence variants in genes related to biliary development and ciliopathies, a notable lack of a cholangiocyte glycocalyx and of submucosal collagen bundles in the neonatal extrahepatic bile ducts, and an innate proinflammatory bias of the neonatal immune system contribute to an increased susceptibility to damage and obstruction following epithelial injury. These advances form the foundation for a future research agenda focused on identifying the environmental and host factor(s) that cause BA, the potential use of population screening, studies of the mechanisms of prominent fibrosis in young infants, determinations of clinical surrogates of disease progression, and the design of clinical trials that target subgroups of patients with initial drainage following HPE. (Hepatology 2018; 00:000-000).
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Affiliation(s)
- Jorge A. Bezerra
- Liver Care Center of Cincinnati Children’s Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rebecca G. Wells
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Cara L. Mack
- Pediatric Liver Center, Children’s Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Saul J. Karpen
- Emory University School of Medicine and Children’s Healthcare of Atlanta, GA, USA
| | - Jay Hoofnagle
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Edward Doo
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Ronald J. Sokol
- Pediatric Liver Center, Children’s Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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30
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Mack CL. Introducing Ronald J. Sokol, M.D.-our 2018 AASLD president. Hepatology 2018; 67:1669-1672. [PMID: 29466842 DOI: 10.1002/hep.29840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 02/12/2018] [Indexed: 12/07/2022]
Affiliation(s)
- Cara L Mack
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
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31
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Mark JA, Mack CL, Marwan AI, Kramer RE. Use of Fully Covered Self-expanding Metal Biliary Stents in Pediatrics: A Case Series. J Pediatr Gastroenterol Nutr 2018; 66:e71-e75. [PMID: 28837510 DOI: 10.1097/mpg.0000000000001723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Endoscopic retrograde cholangiopancreatography is used to manage biliary pathology in pediatric patients. Plastic biliary stents have been used in this population for obstructive lesions and bile leaks; however, they are sometimes not effective due to migration, occlusion, or ineffective sealing. Fully covered self-expanding metal stents (FCSEMS) have larger diameters making them more suitable for some situations. Their use in pediatrics has, however, not been defined. The aim of the present study is to describe our experience with FCSEMS at our institution. METHODS We present a series of all patients who underwent FCSEMS placement at Children's Hospital Colorado including 3 adolescents and 1 young adult with complex medical needs. RESULTS Patient age range was 12 to 24 years and the weight ranged between 36 and 75 kg. All patients underwent previous endoscopic retrograde cholangiopancreatography and 1 or more rounds of plastic stenting without adequate clinical response before consideration of FCSEMS placement. Indications included recalcitrant biliary anastomotic stricture after liver transplant, persistent bile leak after needle perforation, recurrent obstructive choledocholithiasis after cholecystectomy, and malignant biliary stricture. Sizes of FCSEMS depended on patient bile duct size and biliary pathology. Dwell time was 6 to 8 weeks. Three patients had resolution of biliary pathology after FCSEMS therapy. One patient had distal migration of FCSEMS necessitating repeat stenting. There were no adverse events from FCSEMS placement or removal. CONCLUSIONS FCSEMS therapy should be considered in appropriate pediatric patients when plastic biliary stents are not effective. Further studies are needed to evaluate the safety and efficacy of FCSEMS in the pediatric age group.
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Affiliation(s)
- Jacob A Mark
- Section of Gastroenterology, Hepatology and Nutrition and the Digestive Health Institute
| | - Cara L Mack
- Section of Gastroenterology, Hepatology and Nutrition and the Digestive Health Institute
| | - Ahmed I Marwan
- Division of Pediatric Surgery, Colorado Fetal Care Center, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO
| | - Robert E Kramer
- Section of Gastroenterology, Hepatology and Nutrition and the Digestive Health Institute
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Abstract
Biliary atresia is a devastating biliary disease of neonates that results in liver transplantation for the vast majority. The etiology of biliary atresia is unknown and is likely multifactorial, with components of genetic predisposition, environmental trigger and autoimmunity contributing to disease pathogenesis. This review highlights recent work related to investigations of disease pathogenesis in biliary atresia.
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Affiliation(s)
- Alexandra Kilgore
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Digestive Health Institute, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Cara L. Mack
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Digestive Health Institute, Children’s Hospital Colorado, Aurora, CO 80045, USA
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Cotter JM, Mack CL. Primary sclerosing cholangitis: Unique aspects of disease in children. Clin Liver Dis (Hoboken) 2017; 10:120-123. [PMID: 30992770 PMCID: PMC6467120 DOI: 10.1002/cld.672] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 09/11/2017] [Accepted: 09/24/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jillian M. Cotter
- Section of Hospital Medicine, Children's Hospital ColoradoUniversity of Colorado School of Medicine
| | - Cara L. Mack
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital ColoradoUniversity of Colorado School of Medicine, Digestive Health InstituteAuroraCO
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Sundaram SS, Mack CL, Feldman AG, Sokol RJ. Biliary atresia: Indications and timing of liver transplantation and optimization of pretransplant care. Liver Transpl 2017; 23:96-109. [PMID: 27650268 PMCID: PMC5177506 DOI: 10.1002/lt.24640] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 09/10/2016] [Indexed: 12/12/2022]
Abstract
Biliary atresia (BA) is a progressive, fibro-obliterative disorder of the intrahepatic and extrahepatic bile ducts in infancy. The majority of affected children will eventually develop end-stage liver disease and require liver transplantation (LT). Indications for LT in BA include failed Kasai portoenterostomy, significant and recalcitrant malnutrition, recurrent cholangitis, and the progressive manifestations of portal hypertension. Extrahepatic complications of this disease, such as hepatopulmonary syndrome and portopulmonary hypertension, are also indications for LT. Optimal pretransplant management of these potentially life-threatening complications and maximizing nutrition and growth require the expertise of a multidisciplinary team with experience caring for BA. The timing of transplant for BA requires careful consideration of the potential risk of transplant versus the survival benefit at any given stage of disease. Children with BA often experience long wait times for transplant unless exception points are granted to reflect severity of disease. Family preparedness for this arduous process is therefore critical. Liver Transplantation 23:96-109 2017 AASLD.
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Affiliation(s)
- Shikha S. Sundaram
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Cara L. Mack
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Amy G. Feldman
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Ronald J. Sokol
- Digestive Health Institute and Pediatric Liver Center, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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Sheiko MA, Golden-Mason L, Giugliano S, Hurtado CW, Mack CL, Narkewicz MR, Rosen HR. CD4+ and CD8+ T Cell Activation in Children with Hepatitis C. J Pediatr 2016; 170:142-8.e1. [PMID: 26743497 PMCID: PMC4833455 DOI: 10.1016/j.jpeds.2015.11.055] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 10/27/2015] [Accepted: 11/19/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To assess if peripheral T cell populations in children with chronic hepatitis C virus (HCV) infection would show evidence of activation/exhaustion and an attenuated functional response. STUDY DESIGN Compared with adults, children with HCV infection have a higher rate of spontaneous viral clearance. In adults, chronic HCV has been linked to T cell exhaustion. Little is known of the immune status of children with HCV. Peripheral blood mononuclear cells were isolated from 16 children with HCV (6 males, 10 females; mean age 8.6 years, range 2-17), 16 age- and sex-matched control children without HCV infection, and 20 adults with chronic HCV. Multiparameter flow cytometry was performed to characterize T cell differences across the 3 groups. RESULTS Controls and children with HCV had similar levels of CD4(+), CD8(+), and γδ(+) T cells. Children with HCV demonstrated a decrease in naïve T cells compared with control children and increased activation/exhaustion marker expression on both CD8(+) and CD4(+) T cells. Transcription factor analysis suggested functional activation of T cells in children with HCV; however, only the CD4(+) subset had enhanced cytokine production (interferon gamma and interleukin-2) compared with control children. CONCLUSIONS The HCV response in children is characterized by several changes in T cell phenotype. Many of these changes, such as increased T cell expression of programmed cell death-1, are similar to responses in adults. Of note, cytokine production by CD4(+) helper T cells is increased in children with HCV compared with age- and sex-matched control children, which may influence long-term prognosis in children with HCV.
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Affiliation(s)
- Melissa A. Sheiko
- Department of Pediatrics, Digestive Health Institute, Children's Hospital Colorado, University of Colorado Denver School of Medicine
| | - Lucy Golden-Mason
- Division of Gastroenterology and Hepatology, Hepatitis C Center, Department of Medicine, University of Colorado Denver, Aurora, CO
| | - Silvia Giugliano
- Division of Gastroenterology and Hepatology, Hepatitis C Center, Department of Medicine, University of Colorado Denver, Aurora, CO
| | - Christine Waasdorp Hurtado
- Department of Pediatrics, Digestive Health Institute, Children's Hospital Colorado, University of Colorado Denver School of Medicine
| | - Cara L. Mack
- Department of Pediatrics, Digestive Health Institute, Children's Hospital Colorado, University of Colorado Denver School of Medicine
| | - Michael R. Narkewicz
- Department of Pediatrics, Digestive Health Institute, Children's Hospital Colorado, University of Colorado Denver School of Medicine
| | - Hugo R. Rosen
- Division of Gastroenterology and Hepatology, Hepatitis C Center, Department of Medicine, University of Colorado Denver, Aurora, CO,Eastern Colorado Veteran's Affairs Medical Center, Denver, CO
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Abstract
Biliary atresia (BA) is the most frequent identifiable cause of neonatal cholestasis and the majority of patients will need liver transplantation for survival. Despite surgical intervention with the Kasai portoenterostomy, significant fibrosis and cirrhosis develops early in life. An increased understanding of what causes this inflammatory fibrosing cholangiopathy will lead to therapies aimed at protecting the intrahepatic biliary system from immune-mediated damage. This review focuses on studies pertaining to the role of the adaptive immune response in bile duct injury in BA, including cellular and humoral immunity. The neonatal presentation of BA begs the question of what are potential modifications of unique aspects of the neonatal immune system that "sets the stage" for the progressive biliary disease? Throughout this article, characteristics of the neonatal immune response are outlined and theories as to how alterations of this response could contribute to the pathogenesis of BA are discussed. These include aberrant Th1 and Th17 responses, deficiencies in regulatory T cells, activation of humoral immunity and autoimmunity. In order to advance our understanding of the etiology of BA, future studies should focus on those unique aspects of the neonatal immune system that have gone awry, as detailed throughout this review.
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Affiliation(s)
- Cara L. Mack
- Correspondence Address correspondence to: Cara L. Mack, MD, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Mailstop B290, Aurora, Colorado 80045. fax: (720) 777-7277.
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Schwarz KB, Haber BH, Rosenthal P, Mack CL, Moore J, Bove KE, Bezerra JA, Karpen SJ, Kerkar N, Shneider BL, Turmelle YP, Whitington PF, Molleston JP, Murray KF, Ng VL, Romero R, Wang KS, Sokol RJ, Magee JC. Extrahepatic anomalies in infants with biliary atresia: results of a large prospective North American multicenter study. Hepatology 2013; 58:1724-31. [PMID: 23703680 PMCID: PMC3844083 DOI: 10.1002/hep.26512] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 04/28/2013] [Accepted: 05/02/2013] [Indexed: 12/25/2022]
Abstract
UNLABELLED The etiology of biliary atresia (BA) is unknown. Given that patterns of anomalies might provide etiopathogenetic clues, we used data from the North American Childhood Liver Disease Research and Education Network to analyze patterns of anomalies in infants with BA. In all, 289 infants who were enrolled in the prospective database prior to surgery at any of 15 participating centers were evaluated. Group 1 was nonsyndromic, isolated BA (without major malformations) (n = 242, 84%), Group 2 was BA and at least one malformation considered major as defined by the National Birth Defects Prevention Study but without laterality defects (n = 17, 6%). Group 3 was syndromic, with laterality defects (n = 30, 10%). In the population as a whole, anomalies (either major or minor) were most prevalent in the cardiovascular (16%) and gastrointestinal (14%) systems. Group 3 patients accounted for the majority of subjects with cardiac, gastrointestinal, and splenic anomalies. Group 2 subjects also frequently displayed cardiovascular (71%) and gastrointestinal (24%) anomalies; interestingly, this group had genitourinary anomalies more frequently (47%) compared to Group 3 subjects (10%). CONCLUSION This study identified a group of BA (Group 2) that differed from the classical syndromic and nonsyndromic groups and that was defined by multiple malformations without laterality defects. Careful phenotyping of the patterns of anomalies may be critical to the interpretation of both genetic and environmental risk factors associated with BA, allowing new insight into pathogenesis and/or outcome.
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Affiliation(s)
| | | | | | - Cara L Mack
- University of Colorado School of Medicine, Aurora, CO.
| | - Jeffrey Moore
- University of Michigan School of Public Health, Ann Arbor, MI.
| | - Kevin E Bove
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH. ,
| | - Jorge A Bezerra
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH. ,
| | | | | | | | | | | | - Jean P Molleston
- Indiana University, Riley Hospital for Children, Indianapolis, IN.
| | - Karen F Murray
- Seattle Children’s and University of Washington, Seattle, WA.
| | - Vicky L Ng
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
| | | | - Kasper S Wang
- Children’s Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA.
| | | | - John C Magee
- University of Michigan Medical School, Ann Arbor, MI.
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Tucker RM, Feldman AG, Fenner EK, Mack CL. Regulatory T cells inhibit Th1 cell-mediated bile duct injury in murine biliary atresia. J Hepatol 2013; 59:790-6. [PMID: 23685050 PMCID: PMC3855478 DOI: 10.1016/j.jhep.2013.05.010] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 04/30/2013] [Accepted: 05/03/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Biliary atresia (BA) is a pediatric inflammatory disease of the biliary system which leads to cirrhosis and the need for liver transplantation. One theory regarding etiology is that bile duct injury is due to virus-induced autoreactive T cell-mediated inflammation. Regulatory T cell (Treg) abnormalities in BA could result in unchecked bystander inflammation and autoimmunity targeting bile ducts. The aim of this study was to determine if Tregs are dysfunctional in the rotavirus-induced mouse model of BA (murine BA). METHODS Murine BA resulted from infection of BALB/c neonates with Rhesus rotavirus (RRV). RESULTS Liver Tregs from BA mice were decreased in number, activation marker expression, and suppressive function. Adoptive transfer studies revealed that RRV-infected mice that received Tregs had significantly increased survival (84%) compared to controls (12.5%). In addition, ablation of Tregs in older mice, followed by RRV infection, resulted in increased bile duct injury. CONCLUSIONS These studies demonstrate that dysregulation of Tregs is present in murine BA and that diminished Treg function may be implicated in the pathogenesis of human BA.
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Affiliation(s)
| | | | | | - Cara L. Mack
- University of Colorado, Denver,Children’s Hospital Colorado, Denver, CO 80262
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Feldman AG, Tucker RM, Fenner EK, Pelanda R, Mack CL. B cell deficient mice are protected from biliary obstruction in the rotavirus-induced mouse model of biliary atresia. PLoS One 2013; 8:e73644. [PMID: 23991203 PMCID: PMC3749125 DOI: 10.1371/journal.pone.0073644] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/19/2013] [Indexed: 02/04/2023] Open
Abstract
A leading theory regarding the pathogenesis of biliary atresia (BA) is that bile duct injury is initiated by a virus infection, followed by an autoimmune response targeting bile ducts. In experimental models of autoimmune diseases, B cells have been shown to play an important role. The aim of this study was to determine the role of B cells in the development of biliary obstruction in the Rhesus rotavirus (RRV)-induced mouse model of BA. Wild-type (WT) and B cell-deficient (Ig-α(-/-)) mice received RRV shortly after birth. Ig-α(-/-) RRV-infected mice had significantly increased disease-free survival rate compared to WT RRV-infected BA mice (76.8% vs. 17.5%). In stark contrast to the RRV-infected BA mice, the RRV-infected Ig-α(-/-) mice did not have hyperbilirubinemia or bile duct obstruction. The RRV-infected Ig-α(-/-) mice had significantly less liver inflammation and Th1 cytokine production compared to RRV-infected WT mice. In addition, Ig-α(-/-) mice had significantly increased numbers of regulatory T cells (Tregs) at baseline and after RRV infection compared to WT mice. However, depletion of Tregs in Ig-α(-/-) mice did not induce biliary obstruction, indicating that the expanded Tregs in the Ig-α(-/-) mice were not the sole reason for protection from disease. Conclusion : B cell deficient Ig-α(-/-) mice are protected from biliary obstruction in the RRV-induced mouse model of BA, indicating a primary role of B cells in mediating disease pathology. The mechanism of protection may involve lack of B cell antigen presentation, which impairs T-cell activation and Th1 inflammation. Immune modulators that inhibit B cell function may be a new strategy for treatment of BA.
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Affiliation(s)
- Amy G Feldman
- Department of Pediatrics, Section of Pediatric Gastroenterology, Children's Hospital, Colorado, Aurora, Colorado, USA.
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Mack CL, Anderson KM, Aubrey MT, Rosenthal P, Sokol RJ, Freed BM. Lack of HLA predominance and HLA shared epitopes in biliary Atresia. Springerplus 2013; 2:42. [PMID: 23505615 PMCID: PMC3595468 DOI: 10.1186/2193-1801-2-42] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 02/04/2013] [Indexed: 11/17/2022]
Abstract
Biliary atresia (BA) is characterized by progressive inflammation and fibrosis of bile ducts. A theory of pathogenesis entails autoimmune-mediated injury targeting bile duct epithelia. One of the strongest genetic associations with autoimmunity is with HLA genes. In addition, apparently dissimilar HLA alleles may have similar antigen-binding sites, called shared epitopes, that overlap in their capacity to present antigens. In autoimmune disease, the incidence of the disease may be related to the presence of shared epitopes, not simply the HLA allelic association. Aim: To determine HLA allele frequency (high-resolution genotyping) and shared epitope associations in BA. Results: Analysis of every allele for HLA-A, -B, -C, -DRB1, -DPB1 and -DQB1 in 180 BA and 360 racially-matched controls did not identify any significant HLA association with BA. Furthermore, shared epitope analysis of greater than 10 million possible combinations of peptide sequences was not different between BA and controls. Conclusions: This study encompasses the largest HLA allele frequency analysis for BA in the United States and is the first study to perform shared epitope analysis. When controlling for multiple comparisons, no HLA allele or shared epitope association was identified in BA. Future studies of genetic links to BA that involve alterations of the immune response should include investigations into defects in regulatory T cells and non-HLA linked autoinflammatory diseases.
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Affiliation(s)
- Cara L Mack
- Departments of Medicine and Immunology, Division of Allergy and Clinical Immunology, University of Colorado School of Medicine, 80045 Aurora, CO USA ; Department of Pediatrics, Division of Pediatric Gastroenterology, Digestive Health Institute, Children's Hospital Colorado, Hepatology and Nutrition, 13123 East 16th Ave. B290, 80045 Aurora, CO USA
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Abstract
Biliary atresia (BA) is an infantile obstructive cholangiopathy of unknown etiology with suboptimal therapy, which is responsible for 40 to 50% of all pediatric liver transplants. Although the etiology of bile duct injury in BA in unknown, it is postulated that a pre- or perinatal viral infection initiates cholangiocyte apoptosis and release of antigens that trigger a Th1 immune response that leads to further bile duct injury, inflammation, and obstructive fibrosis. Humoral immunity and activation of the innate immune system may also play key roles in this process. Moreover, recent investigations from the murine BA model and human data suggest that regulatory T cells and genetic susceptibility factors may orchestrate autoimmune mechanisms. What controls the coordination of these events, why the disease only occurs in the first few months of life, and why a minority of infants with perinatal viral infections develop BA are remaining questions to be answered.
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Affiliation(s)
- Cara L. Mack
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, and Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Amy G. Feldman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, and Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Ronald J. Sokol
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, and Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado
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Abstract
The cause of biliary atresia is unknown; in the past few decades, the majority of investigations related to its pathogenesis have centered on viral infections and immunity. The acquired or perinatal form of biliary atresia entails a progressive inflammatory injury of bile ducts, leading to fibrosis and obliteration of both the extrahepatic and intrahepatic bile ducts. Theories of pathogenesis include viral infection, chronic inflammatory or autoimmune-mediated bile duct injury, and abnormalities in bile duct development. This review will focus solely on human studies pertaining to a potential viral trigger of bile duct injury at diagnosis and provide insight into the interplay of the innate and adaptive immune responses in the pathogenesis of disease.
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Tucker RM, Mack CL. Generation of a cholangiocyte-specific cDNA expression library for the identification of B and T cell autoantigens in murine biliary disease. Hepatol Res 2012; 42:502-7. [PMID: 22236071 PMCID: PMC3798039 DOI: 10.1111/j.1872-034x.2011.00951.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Several mouse models of inflammatory cholangiopathies exist, including biliary atresia, primary biliary cirrhosis, autoimmune hepatitis, and primary sclerosing cholangitis. In an ongoing effort to identify the target antigens of both infiltrating autoreactive T cells and serum autoantibodies, we aimed to generate a cholangiocyte-derived cDNA library capable of expressing a wide variety of proteins. METHODS mRNA was isolated from a normal mouse cholangiocyte cell line and reverse transcribed into cDNA. After initial cloning of the cDNA into a transfer vector (pDONR222), the entire library was shuttled into an Escherichia coli expression vector (pDEST160). RESULTS The library contains 2.3 × 10(6) independent clones and expresses proteins up to 100 kD in molecular weight. Using a variety of techniques, including western blot analysis, mass spectrometry of individual clones, and direct DNA sequencing of plasmids, a number of both ubiquitously expressed and cholangiocyte-specific proteins (e.g. cytokeratin 19) have been identified within. CONCLUSION A comprehensive mouse cholangiocyte cDNA expression library has been generated and is available for use as a source of multiple cholangiocyte-specific antigens for immunological studies. The library can be used to screen for specificity of T cell lines or hybridomas. Furthermore, this library has potential uses in SEREX analysis of autoantibody reactivity. The cholangiocyte-specific cDNA library is a powerful tool for the identification of target antigens in murine inflammatory cholangiopathies and is available as a shared resource.
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Affiliation(s)
| | - Cara L. Mack
- Department of Medicine, University of Colorado, Denver,Department of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, Aurora, Colorado, USA
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Brindley SM, Lanham AM, Karrer FM, Tucker RM, Fontenot AP, Mack CL. Cytomegalovirus-specific T-cell reactivity in biliary atresia at the time of diagnosis is associated with deficits in regulatory T cells. Hepatology 2012; 55:1130-8. [PMID: 22105891 PMCID: PMC3319336 DOI: 10.1002/hep.24807] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
UNLABELLED Biliary atresia (BA) is a progressive, inflammatory cholangiopathy that culminates in fibrosis of extrahepatic and intrahepatic bile ducts. A leading theory on the pathogenesis of BA is that the bile duct damage is initiated by a virus infection, followed by a bile duct-targeted autoimmune response. One mechanism of autoimmunity entails a diminished number or function of regulatory T cells (Tregs). The aim of this study was to identify potential virus-specific liver T cells from infants with BA at the time of diagnosis, implicating the virus involved in early bile duct damage. A subaim was to determine if the presence of virus infection was associated with quantitative changes in Tregs. Liver T cells from BA and control patients were cultured with antigen-presenting cells in the presence of a variety of viral or control proteins. 56% of BA patients had significant increases in interferon-gamma-producing liver T cells in response to cytomegalovirus (CMV), compared with minimal BA responses to other viruses or the control group CMV response. In addition, a positive correlation between BA plasma CMV immunoglobulin M (IgM) and liver T-cell CMV reactivity was identified. Investigation of peripheral blood Tregs revealed significant deficits in Treg frequencies in BA compared with controls, with marked deficits in those BA patients who were positive for CMV. CONCLUSION Liver T-cell responses to CMV were identified in the majority of BA patients at diagnosis, suggesting perinatal CMV infection as a plausible initiator of bile duct damage. Deficiency of Tregs in BA implies decreased inhibition of inflammation and autoreactivity, potentially allowing for exaggerated bile duct injury.
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Affiliation(s)
- Stephen M. Brindley
- Division of Allergy & Clinical Immunology, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Allison M. Lanham
- Division of Allergy & Clinical Immunology, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Frederick M. Karrer
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Digestive Health Institute, Children’s Hospital Colorado, Aurora, Colorado
| | - Rebecca M. Tucker
- Division of Allergy & Clinical Immunology, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Andrew P. Fontenot
- Division of Allergy & Clinical Immunology, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Cara L. Mack
- Division of Allergy & Clinical Immunology, University of Colorado Denver School of Medicine, Aurora, Colorado,Division of Pediatric Gastroenterology, Hepatology & Nutrition, Digestive Health Institute, Children’s Hospital Colorado, Aurora, Colorado
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Mack CL, Wilhelmi B, Duncan JR, Burgess JE. Biosorptive recovery of platinum from platinum group metal refining wastewaters by immobilised Saccharomyces cerevisiae. Water Sci Technol 2011; 63:149-155. [PMID: 21245567 DOI: 10.2166/wst.2011.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The process of platinum group metal (PGM) refining can be up to 99.99% efficient at best, and although it may seem small, the amount of valuable metal lost to waste streams is appreciable enough to warrant recovery. The method currently used to remove entrained metal ions from refinery wastewaters, chemical precipitation, is not effective for selective recovery of PGMs. The yeast Saccharomyces cerevisiae has been found capable of sorbing numerous precious and base metals, and is a cheap and abundant source of biomass. In this investigation, S. cerevisiae was immobilised using polyethyleneimine and glutaraldehyde to produce a suitable sorbent, capable of high platinum uptake (150-170 mg/g) at low pH (<2). The sorption mechanism was found to be a chemical reaction, which made effective desorption impossible. When applied to PGM refinery wastewater, two key wastewater characteristics limited the success of the sorption process; high inorganic ion content and complex speciation of the platinum ions. The results proved the concept principle of platinum recovery by immobilised yeast biosorption and indicated that a more detailed understanding of the platinum speciation within the wastewater is required before biosorption can be applied. Overall, the sorption of platinum by the S. cerevisiae sorbent was demonstrated to be highly effective in principle, but the complexity of the wastewater requires that pretreatment steps be taken before the successful application of this process to industrial wastewater.
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Affiliation(s)
- C L Mack
- Department of Biochemistry Microbiology and Biotechnology, Rhodes University, PO Box 94, Grahamstown, 6140, South Africa
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Rand EB, Karpen SJ, Kelly S, Mack CL, Malatack JJ, Sokol RJ, Whitington PF. Treatment of neonatal hemochromatosis with exchange transfusion and intravenous immunoglobulin. J Pediatr 2009; 155:566-71. [PMID: 19560784 DOI: 10.1016/j.jpeds.2009.04.012] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Revised: 01/27/2009] [Accepted: 04/08/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine if immunomodulatory treatment including intravenous immunoglobulin (IVIG) can favorably affect survival in neontatal hemochromatosis (NH) diagnosed postnatally because it can effectively prevent occurrence of NH when applied during gestations at risk. STUDY DESIGN We treated 16 newborn infants with liver failure due to NH with high-dose IVIG, in combination with exchange transfusion in 13 (ET/IVIG), and compared the outcome with 131 historical controls treated conventionally. RESULTS The severity of liver disease as estimated by prothrombin time was similar in the subjects receiving ET/IVIG and the historical controls, and the medical therapy was equivalent with the exception of the ET/IVIG therapy. Twelve subjects (75%) had good outcome, defined as survival without liver transplantation, whereas good outcome was achieved in only 17% (23/131) of historical control patients (P < .001). Four subjects died, 2 without and 2 after liver transplant. Survivors were discharged 6 to 90 days after receiving ET/IVIG therapy, and those followed for more than 1 year are within normal measures for growth, development, and liver function. CONCLUSIONS Immune therapy with ET/IVIG appears to improve the outcome and reduce the need for liver transplantation in patients with NH.
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Affiliation(s)
- Elizabeth B Rand
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Abstract
BACKGROUND/AIMS Biliary atresia (BA) is a progressive disease characterized by bile duct inflammation and fibrosis. The aetiology is unknown and may be due to a virus-induced, autoimmune-mediated injury of cholangiocytes. Cholangiocytes are not only targets of injury but may also modulate hepatic inflammation. The aim of this study was to determine the immune profile of murine cholangiocytes and the ability to function as antigen-presenting cells (APCs) in culture with Rhesus rotavirus (RRV), poly I:C (viral mimic) or interferon-gamma/tumour necrosis factor-alpha. METHODS/RESULTS Both the cholangiocyte cell line (long-term culture) and fresh, ex vivo cholangiocytes expressed APC surface markers major histocompatibility complex (MHC)-class I and II and CD40, while only the cultured cell line expressed costimulatory molecules B7-1 and B7-2. Despite APC expression, cultured cholangiocytes were unable to function as competent APCs in T-cell proliferation assays. Furthermore, both cultured and ex vivo cholangiocytes expressed RNA transcripts for many pro-inflammatory cytokines and chemokines. CONCLUSIONS Although cholangiocytes contain APC molecules, they are incompetent at antigen presentation and cannot elicit effective T-cell activation. Upregulation of MHC-class I and II found in BA mice may serve to prime the cholangiocyte as a target for immune-mediated injury. Cholangiocytes produced many pro-inflammatory cytokines and chemokines in the setting of RRV infection and T-helper type 1 cytokine milieu, suggesting a role of cholangiocytes as immune modulators promoting the ongoing inflammation that exists in RRV-induced BA.
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Affiliation(s)
- Barrett H. Barnes
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology & Nutrition, The Children's Hospital, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Rebecca M. Tucker
- Department of Medicine, Division of Allergy and Clinical Immunology, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Fabian Wehrmann
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology & Nutrition, The Children's Hospital, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Doug G. Mack
- Department of Medicine, Division of Allergy and Clinical Immunology, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Yoshiyuki Ueno
- Department of Medicine, Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Cara L. Mack
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology & Nutrition, The Children's Hospital, University of Colorado Denver School of Medicine, Aurora, CO, USA, Department of Medicine, Division of Allergy and Clinical Immunology, University of Colorado Denver School of Medicine, Aurora, CO, USA
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Abstract
Biliary atresia is a mystifying cause of neonatal cholestasis, manifested by progressive inflammation and fibrosis of both the extrahepatic and intrahepatic bile ducts. It is a devastating disease that leads to cirrhosis and the need for liver transplantation in the majority of children. The etiology is unknown, and one theory is that it may involve a primary perinatal hepatobiliary viral infection and a secondary generation of an autoimmune-mediated bile duct injury. This review will outline the evidence from both human and murine studies supporting a potential cholangiotropic viral infection as the initiator of bile duct injury in biliary atresia and the role of the adaptive immune response and autoimmunity in progression of disease. Delineating the pathways of immune and autoimmune-mediated bile duct injury within biliary atresia could stimulate development of new medical interventions aimed at suppressing the specific immune response, decreasing the inflammatory damage to bile ducts, and delaying or negating the need for liver transplantation.
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Affiliation(s)
- Cara L Mack
- Pediatric Liver Center and Liver Transplant Program, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital, University of Colorado at Denver-Health Sciences Center, Denver, Colorado 80218, USA
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Tucker RM, Hendrickson RJ, Mukaida N, Gill RG, Mack CL. Progressive biliary destruction is independent of a functional tumor necrosis factor-alpha pathway in a rhesus rotavirus-induced murine model of biliary atresia. Viral Immunol 2007; 20:34-43. [PMID: 17425419 PMCID: PMC1978183 DOI: 10.1089/vim.2006.0088] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Rhesus rotavirus (RRV)-inoculated neonatal BALB/c mice develop an immune-mediated inflammation of extra- and intrahepatic bile ducts that progresses to biliary obstruction and death by 3 wk of age. Livers of diseased animals demonstrate increased numbers of T lymphocytes with elevated expression of helper T cell type 1 (Th1) cytokines at 1 wk, which transitions to increased numbers of macrophages and high expression of the proinflammatory cytokine tumor necrosis factor (TNF)-alpha by 2 wk. We employed both pharmacologic and genetic approaches for attenuation of TNF-alpha to determine whether it plays a causal role in injury. First, RRV-inoculated BALB/c mice were subjected to multiple treatments with either the TNF receptor I (TNF-RI)-Fc fusion protein etanercept or neutralizing antibodies to mouse TNF-alpha. Also, TNF-RI(-/-) mice were injected with RRV in the same manner as wild-type mice. In all cases, TNF inhibition did not reduce the severity or incidence of disease. Survival curves of mice given blocking agents were similar to those of control RRV-inoculated mice, and survival of challenged TNF-RI(-/-) mice was worse than that of wild-type mice, likely because of the prolonged presence of infectious RRV. In all experimental groups, markers of disease were unchanged from those of control mice. In summary, although RRV-inoculated BALB/c mice have highly elevated expression of TNF-alpha, this cytokine does not play an obligate role in disease progression.
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Affiliation(s)
- Rebecca M Tucker
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado 80262, USA.
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