Association of nonsense mutation of dystrophin gene with disruption of sarcoglycan complex in X-linked dilated cardiomyopathy

BACKGROUND

In a systematic analysis of inherited forms of cardiomyopathy, we previously identified a family with X-linked dilated cardiomyopathy characterised by a mutation in the rod region of dystrophin. We have now attempted to eludicate the genetic mechanism involved in this disease, as well as the role of dystrophin-associated glycoproteins.

METHODS

The affected dystrophin epitope, which lacks binding to the dys-1 antibody, was analysed by single-strand conformation polymorphism analysis, reverse-transcription PCR, and DNA sequencing. Effects on dystrophin-associated glycoproteins were studied by immunohistochemistry and western blotting.

FINDINGS

A translation-termination mutation (C4148T) in exon 29 of the dystrophin gene was found in all affected family members. Alternative splicing rescued the reading frame and led to the expression of a dystrophin molecule lacking 50 aminoacids both in cardiac and skeletal muscle. Immunohistochemical analysis of the dystrophin-associated proteins revealed a reduction of beta-sarcoglycan and delta-sarcoglycan in the sarcolemma of cardiac muscle but not skeletal muscle tissue. However, western blotting revealed similar amounts of sarcoglycan subunits in both tissues.

INTERPRETATION

The molecular mechanism of this subtype of X-linked cardiomyopathy may be explained by a conformational change in exon-29-deleted dystrophin, resulting in disruption of the sarcoglycan assembly in heart muscle but not skeletal muscle.

Assembly of human papillomavirus type 16 pseudovirions in Saccharomyces cerevisiae

Studies of the encapsidation of papillomavirus (PV) DNA, and production of preparative amounts of PVs in vitro, have met with only limited success. To circumvent this problem we established a system in yeast to generate infectious HPV-16 pseudovirions. Saccharomyces cerevisiae strain 1699 was transformed with a construct to allow production of HPV-16 virus-like particles (VLPs). This strain was then transformed with a second construct (target plasmid), the same size as the HPV-16 genome and containing the HPV-16 upstream regulatory region (URR) and the HPV-16 E2 open reading frame. In addition, the target plasmid contained the green fluorescent protein gene to monitor delivery of the target plasmid into mammalian cells after infection. We conclude that this system allows HPV DNA encapsidation because (1) HPV-16 VLPs of two different types (heavy and light) were detected by CsCl gradient centrifugation, (2) DNase I-resistant DNA was detected by PCR/Southern blot analysis in fractions of CsCl gradients at a density corresponding to heavy VLPs, (3) in vitro infection of mammalian cells, including primary mouse splenocytes, with pseudovirions resulted in delivery of the reporter gene as demonstrated by FACS analysis for GFP expression, and (4) after injection of pseudovirions into mice, in vivo reporter gene expression was detected by confocal microscopy in sections of muscle tissue. We conclude that HPV-16 pseudovirions produced in yeast may be useful both for in vitro transduction and for gene delivery in vivo.

Hemodynamic effects of hypertonic hydroxyethyl starch 6% solution and isotonic hydroxyethyl starch 6% solution after declamping during abdominal aortic aneurysm repair

Fluid resuscitation with hypertonic hydroxyethyl starch solutions (HES) is effective in haemorrhagic shock due to the rapid mobilisation of fluids into the intravascular compartment. Declamping of the abdominal aorta with acute redistribution of blood into the vessels of the lower body half causes declamping-induced hypotension. Usually large amount of fluids or vasopressors are necessary to restore hemodynamic stability. Therefore, infusion of a hypertonic colloid solution may be an attractive option to achieve hemodynamic stability. This study was conducted to determine the amount of fluid of either hypertonic HES (HES 6%;7.2% NaCl) or isotonic HES (HES 6%;0.9% NaCl) needed to attain best wedge pressure (PCWP) cardiac index (CI) relation after declamping. Thirty-two high-risk patients undergoing elective abdominal aneurysm resection were enrolled in a prospective, randomised, double blinded study. The individual optimised PCWP/CI relation was determined after induction of anaesthesia. After declamping, both solutions were titrated in small boluses of 100 mL until the previously determined best wedge was reached. The amount of fluid after declamping was significantly reduced in the hypertonic HES- group 162 mL vs. 265 mL in the control group (P < 0.05). Resuscitation time was shortened, and cardiac index was slightly higher in the treatment group. The use of hypertonic HES-solution after aortic declamping led to a significant reduction of fluids necessary to attain optimised PCWP/CI relation. In this clinical trial with moderate blood loss in high-risk patients, hypertonic HES applied in a titrated fashion restored hemodynamic stability faster and without volume overload.

Orientation of the infrared transition moments for an alpha-helix

Appropriate values for the orientation of the amide transition dipoles are essential to the growing use of isotopically edited vibrational spectroscopy generally in structural biology and to infrared dichroism measurements on membrane-associated alpha-helices, in particular. The orientations of the transition moments for the amide vibrations of an alpha-helix have been determined from the ratio of intensities of the A- and E(1)-symmetry modes in the infrared spectra of poly(gamma-methyl-L-glutamate)(x)-co-(gamma-n-octadecyl-L-glutamate)( y) oriented on silicon substrates. Samples possessing a high degree of alignment were used to facilitate band fitting. Consistent results were obtained from both attenuated total reflection and transmission experiments with polarized radiation, yielding values of Theta(I) = 38 degrees, Theta(II) = 73 degrees, and Theta(A) = 29 degrees, relative to the helix axis, for the amide I, amide II, and amide A bands, respectively. The measurements are discussed both in the context of the somewhat divergent older determinations, and in relation to the helix geometry and results on model amide compounds, to resolve current uncertainties in the literature.

Micellar electrokinetic chromatography for the analysis of cefpirome in microdialysis and plasma samples obtained in vivo from human volunteers

Pharmacokinetics of drugs in the human interstitial space fluid can be monitored by means of microdialysis. However, the small-volume microdialysis samples containing low drug concentrations require a sensitive analytical method. In the present study, micellar electrokinetic chromatography (MEKC) is described for the quantification of cefpirome in human microdialysis and plasma samples. Sample preparation of human plasma samples by ultracentrifugation was suitable for comparison of plasma and microdialysate concentrations. Limits of quantification were 2 microg/mL and 0.3 microg/mL for plasma and microdialysate samples, respectively. The limit of detection (LOD) was estimated at 0.2 microg/mL for the plasma and microdialysate samples. In conclusion, MEKC is a reliable and reproducible technique for measuring cefpirome concentrations in microdialysates as well as centrifuged plasma samples.

Cryopreparation provides new insight into the effects of brefeldin A on the structure of the HepG2 Golgi apparatus

High-pressure freezing and freeze-substitution were used to study Golgi ultrastructure and its brefeldin A-induced transformations in HepG2 human hepatoma cells. Cryoimmobilization arrested subcellular dynamics within milliseconds, thus considerably improving the temporal resolution in monitoring the very early effects of high brefeldin concentrations at the ultrastructural level (i.e., 20 microg/ml brefeldin applied for 35 s to 8 min). Moreover, this approach ruled out possible cumulative and/or synergistic effects of the drug and fixatives. Several findings differed from studies based on chemical fixation. In particular, Golgi breakdown did not proceed gradually but occurred in distinct steps. We found a conspicuous lag between the absence of nonclathrin coats on Golgi membranes after 30 s of brefeldin treatment and the disassembly of the stacks, which did not start until after 90 to 120 s. At this time, domains at the trans and cis faces separated from the stacks, starting tubulation and fragmentation. After 3-5 min the Golgi apparatus was completely replaced by loose meshworks of straight tubules of different sizes and staining properties; also frequent were bent tubules and vesicles forming glomerule-like structures. After 8 min all kinds of Golgi-derived structures had aggregated within huge clusters. The morphologically highly distinct structures found after brefeldin treatment could in part be correlated with particular Golgi domains in the control cells.

Benzoylformate decarboxylase from Pseudomonas putida as stable catalyst for the synthesis of chiral 2-hydroxy ketones

The thiamin diphosphate- and Mg2+-dependent enzyme benzoylformate decarboxylase (BFD) from Pseudomonas putida was characterized with respect to its suitability to catalyze the formation of chiral 2-hydroxy ketones in a benzoin-condensation type reaction. Carboligation constitutes a side reaction of BFD, whereas the predominant physiological task of the enzyme is the non-oxidative decarboxylation of benzoylformate. For this purpose the enzyme was obtained in sufficient purity from Pseudomonas putida cells in a one-step purification using anion-exchange chromatography. To facilitate the access to pure BFD for kinetical studies, stability investigations, and synthetical applications, the coding gene was cloned into a vector allowing the expression of a hexahistidine fusion protein. The recombinant enzyme shows distinct activity maxima for the decarboxylation and the carboligation beside a pronounced stability in a broad pH and temperature range. The enzyme accepts a wide range of donor aldehyde substrates which are ligated to acetaldehyde as an acceptor in mostly high optical purities. The enantioselectivity of the carboligation was found to be a function of the reaction temperature, the substitution pattern of the donor aldehyde and, most significantly, of the concentration of the donor aldehyde substrate. Our data are consistent with a mechanistical model based on the X-ray crystallographic data of BFD. Furthermore we present a simple way to increase the enantiomeric excess of (S)-2-hydroxy-1-phenyl-propanone from 90% to 95% by skillful choice of the reaction parameters. Enzymatic synthesis with BFD are performed best in a continuously operated enzyme membrane reactor. Thus, we have established a new enzyme tool comprising a vast applicability for stereoselective synthesis.

Visual contributions to human self-motion perception during horizontal body rotation

It is still an enigma how human subjects combine visual and vestibular inputs for their self-motion perception. Visual cues have the benefit of high spatial resolution but entail the danger of self motion illusions. We performed psychophysical experiments (verbal estimates as well as pointer indications of perceived self-motion in space) in normal subjects (Ns) and patients with loss of vestibular function (Ps). Subjects were presented with horizontal sinusoidal rotations of an optokinetic pattern (OKP) alone (visual stimulus; 0.025-3.2 Hz; displacement amplitude, 8 degrees) or in combinations with rotations of a Bárány chair (vestibular stimulus; 0.025-0.4 Hz; +/- 8 degrees). We found that specific instructions to the subjects created different perceptual states in which their self-motion perception essentially reflected three processing steps during pure visual stimulation: i) When Ns were primed by a procedure based on induced motion and then they estimated perceived self-rotation upon pure optokinetic stimulation (circular vection, CV), the CV has a gain close to unity up to frequencies of almost 0.8 Hz, followed by a sharp decrease at higher frequencies (i.e., characteristics resembling those of the optokinetic reflex, OKR, and of smooth pursuit, SP). ii) When Ns were instructed to "stare through" the optokinetic pattern, CV was absent at high frequency, but increasingly developed as frequency was decreased below 0.1 Hz. iii) When Ns "looked at" the optokinetic pattern (accurately tracked it with their eyes) CV was usually absent, even at low frequency. CV in Ps showed similar dynamics as in Ns in condition i), independently of the instruction. During vestibular stimulation, self-motion perception in Ns fell from a maximum at 0.4 Hz to zero at 0.025 Hz. When vestibular stimulation was combined with visual stimulation while Ns "stared through" OKP, perception at low frequencies became modulated in magnitude. When Ns "looked" at OKP, this modulation was reduced, apart from the synergistic stimulus combination (OKP stationary) where magnitude was similar as during "staring". The obtained gain and phase curves of the perception were incompatible with linear systems prediction. We therefore describe the present findings by a non-linear dynamic model in which the visual input is processed in three steps: i) It shows dynamics similar to those of OKR and SP; ii) it is shaped to complement the vestibular dynamics and is fused with a vestibular signal by linear summation; and iii) it can be suppressed by a visual-vestibular conflict mechanism when the visual scene is moving in space. Finally, an important element of the model is a velocity threshold of about 1.2 degrees/s which is instrumental in maintaining perceptual stability and in explaining the observed dynamics of perception. We conclude from the experimental and theoretical evidence that self-motion perception normally is related to the visual scene as a reference, while the vestibular input is used to check the kinematic state of the scene; if the scene appears to move, the visual signal becomes suppressed and perception is based on the vestibular cue.

Relationship between in vivo drug exposure of the tumor interstitium and inhibition of tumor cell growth in vitro: a study in breast cancer patients

A novel approach is described to simulate effect site pharmacodynamics of anticancer drugs. This approach is based on (i) the in vivo measurement of unbound, interstitial drug pharmacokinetics (PK) in solid tumor lesions in patients and (ii) a subsequent pharmacodynamic (PD) simulation of the time versus drug concentration profile in an in vitro setting. For this purpose, breast cancer cells (MCF-7) were exposed in vitro to the time versus interstitial tumor concentration profiles of 5-fluorouracil (5-FU) and methotrexate (MTX) from primary breast cancer lesions in patients. This led to a maximal reduction in the viable cell count of 69% on day 4, and of 71% on day 7 for 5-FU and MTX, respectively. This effect was dependent on the initial cell count and was characterized by a high interindividual variability. For 5-FU there was a significant correlation between the maximum antitumor effect and the intratumoral AUC (r = -0.82, p = 0.0005), whereas no correlation could be shown for MTX (r = 0.05, p = 0.88). We conclude, that the in-vivo-PK / in-vitro-PD model presented in this study may provide a rational approach for describing and predicting pharmacodynamics of cytotoxic drugs at the target site. Data derived from this approach support the concept that tumor penetration of 5-FU may be a response-limiting event, while the response to MTX may be determined by events beyond interstitial fluid kinetics.

Paracrine effects of angiotensin-converting-enzyme- and angiotensin-II-receptor- inhibition on transcapillary glucose transport in humans

The paracrine renin-angiotensin-system (RAS) is increasingly recognized to play an important role in the regulation of both, regional vascular tone and regional glucose metabolism. To date, however, a selective investigation of paracrine RAS effects in an in vivo clinical setting was beyond technical reach. We here set out to selectively study the metabolic effects of paracrine RAS inhibition at different levels in healthy volunteers (n = 8). For this purpose bradykinin, enalaprilate and losartan were administered locally to the interstitial space fluid in skeletal muscle by means of reverse microdialysis and transcapillary glucose transport was measured simultaneously. During reverse microdialysis with bradykinin and enalaprilate a significant decrease in arterial-interstitial-gradient for glucose (AIG(glu)) was observed (from 1.49 +/- 0.08 mM to 0.12 +/- 0.63 mM (p = 0.018) for bradykinin and from 1.5 +/- 0.07 mM to 0.24 +/- 0.67 mM (p = 0.043) for enalaprilate). In contrast, losartan had no effect on AIG(glu). The changes in transcapillary glucose transport during bradykinin and enalaprilate administration were accompanied by significant increases in interstitial lactate levels which was most pronounced for bradykinin (from 0.14 +/- 0.01 mM to 0.40 +/- 0.07 mM, p = 0.018). We conclude that paracrine angiotensin-converting-enzyme (ACE) inhibition but not angiotensin II (AT-II) receptor blockade decreases AIG(glu) and facilitates transcapillary glucose transport due to an increase in interstitial bradykinin concentration. These results support the concept that blood pressure control with ACE-inhibitors but not with AT-II-receptor-antagonists has beneficial long term metabolic consequences in hypertensive, hyperinsulinemic subjects.

Telomerase activity and expression of telomerase subunits in the testicular tissue of infertile patients

OBJECTIVE

Determination of telomerase activity and the expression of human telomerase RNA (hTR) and human telomerase reverse transcriptase (hTERT) in the testicular tissue of patients with infertility arising from various causes.

DESIGN

Prospective observational study.

SETTING

A university hospital.

PATIENT(S)

Thirty-three patients with azoospermia arising from various causes. There were 12 testicular biopsy specimens from patients with Sertoli cell-only syndrome, 9 from patients with maturation arrest, and 12 from patients with obstructive azoospermia and normal histologic findings.

INTERVENTION(S)

Thirty-three testicular biopsies.

MAIN OUTCOME MEASURE(S)

Correlation of histologic findings at testicular biopsy with telomerase activity, hTERT, and hTR.

RESULT(S)

All 12 biopsy specimens from patients with obstructive azoospermia were positive for telomerase activity, hTR, and hTERT. Biopsy specimens from the 9 patients with maturation arrest were positive for telomerase activity in 8 cases, hTR in 9 cases, and hTERT in 5 cases. None of the patients with Sertoli cell-only syndrome showed either telomerase activity or hTERT, but all of them showed hTR.

CONCLUSION(S)

Telomerase activity and evidence of hTERT in testicular tissue are highly sensitive and highly specific markers of gametogenesis, which could gain in importance as part of the fertility workup before microinjection procedures.

Down-regulation of SP1 DNA binding activity in the process of radiation-induced pulmonary fibrosis

PURPOSE

To determine changes in the expression and function of the transcription factor SP1 in radiation-induced pulmonary fibrosis.

MATERIALS AND METHODS

The right lungs of female Fischer rats were irradiated with a fibrogenic single dose of 20 Gy gamma-irradiation. SP1 mRNA and protein expression was determined by Northern and Western blotting, respectively, between 30 min and 12 weeks after irradiation. Cellular localization of SP1 protein was characterized by immunohistochemistry (peroxidase labelling). SP1 DNA binding activity was studied with electrophoretic mobility shift assays (EMSA).

RESULTS

Eight weeks after irradiation, pulmonary fibrosis was first observed. SP1 DNA binding activity showed a short-term increase from 30 min to 12 h after irradiation. Thereafter it remained quite stable until 1 month after irradiation. However, 2 months after irradiation, SP1 DNA binding activity was no longer detectable. The SP1 mRNA level was not reduced at this time, nor was there a reduction in its size. However, Western blotting revealed the occurrence of at least two slightly smaller additional bands 2 months after irradiation whereas the original SP1 band vanished. This suggests a degradation event of SP1 taking place near one or both ends of the protein. Most of the SP1 protein was found in type II pneumocytes and alveolar macrophages of the normal and fibrotic lung. Bronchial epithelial cells were also positive. In the fibrotic lung, proliferating fibroblasts also become positive.

CONCLUSIONS

The functional knockout of the transcription factor SP1, in the process of irradiation-induced pulmonary fibrosis, is demonstrated. This should help elucidate the severe disturbances in transcriptional regulation, cellular proliferation and differentiation occurring in the lung at long intervals after irradiation.

Progress in Arabidopsis genome sequencing and functional genomics

Arabidopsis thaliana has a relatively small genome of approximately 130 Mb containing about 10% repetitive DNA. Genome sequencing studies reveal a gene-rich genome, predicted to contain approximately 25000 genes spaced on average every 4.5 kb. Between 10 to 20% of the predicted genes occur as clusters of related genes, indicating that local sequence duplication and subsequent divergence generates a significant proportion of gene families. In addition to gene families, repetitive sequences comprise individual and small clusters of two to three retroelements and other classes of smaller repeats. The clustering of highly repetitive elements is a striking feature of the A. thaliana genome emerging from sequence and other analyses.

Partial leptin receptor gene deletion in transgenic mice prevents expression of the membrane-bound isoforms except for Ob-Rc

Examination of random insertional mutations in transgenic animals harbouring an abnormal phenotype contributes to the discovery of new genes and/or the understanding of already known genes. Here we describe a transgenic mouse line showing early-onset obesity as consequence of the transgene insertion. Molecular genetic analysis revealed a partial deletion of the leptin receptor (Lepr, Ob-R) gene including the coding sequences downstream of exon 17'. This defect prevents the expression of all described membrane-bound isoforms of Ob-R except for isoform Ob-Rc in the homozygous transgenic animals. Thus, this mouse model might be useful for the investigation of the function of the short Ob-R isoforms.

Contrasting obesity phenotypes uncovered by partial leptin receptor gene deletion in transgenic mice

Non-insulin-dependent diabetes mellitus (type 2 diabetes) is known to be a polygenic and polyfactorial disorder. Here we describe the long-term examination of a transgenic mouse line showing the disruption of the leptin receptor (Lepr, Ob-R) gene caused by transgene insertion. The absence of the expression of the long isoform Ob-Rb uncovered a strong variation of the obesity and diabetes phenotype in the homozygous mutant mice of the outbred strain used. One part of the homozygous mice developed severe persistent early-onset obesity, whereas the other part developed cachexia after having shown initial obesity in the examination period up to 26 weeks p.p. The leptin-receptor-defective mice of this line might serve as a model for the investigation of genes modulating the development and mode of expression of diabetes.

Effect of intraoperative angiotensin-converting enzyme inhibition by quinaprilat on hypertension after coronary artery surgery

Activation of the renin-angiotensin system during cardiopulmonary bypass (CPB) may be involved in early postoperative hypertension after coronary artery bypass grafting (CABG). As hypertensive episodes may be deleterious in the immediate postoperative period, we have assessed the effects of prophylactic treatment with the angiotensin-converting enzyme inhibitor quinaprilat in an open study. During steady state CPB, patients received quinaprilat 0.02 mg kg-1 (group A, n = 10), quinaprilat 0.04 mg kg-1 (group B, n = 10) or saline solution (group C, n = 10) as an i.v. bolus dose. Sodium nitroprusside (SNP) was given after operation when systolic arterial pressure was > 150 mm Hg. Requirements for SNP 1 h after arrival in the ICU were significantly less in groups A (two of 10) and B (two of 10) than in group C (eight of 10). Also, patients in group C had a greater systolic arterial pressure compared with groups A and B. There were no significant differences between groups in diastolic arterial pressure, heart rate, cardiac index or cardiac filling pressures. We conclude that quinaprilat can be used during CABG to reduce the incidence of postoperative hypertension. Further studies of the efficacy and safety of this technique are necessary.

Assessment of genetic relatedness of vaginal isolates of Candida albicans from different geographical origins

PCR fingerprinting with single non-specific primers was used to type vaginal isolates of C. albicans from Portugal, Angola, Madagascar, and two regions of Germany (Berlin and Munich). In addition to analysing isolates that exhibited the normal biotype of C. albicans, the study included atypical strains that failed to assimilate glucosamine and N-acetylglucosamine, which were isolated from women in Angola and Madagascar. A total of 212 strains of C. albicans were studied, representing 87 different multi-locus genotypes. The genotypes of strains from each geographical population were highly similar but not identical. There was one exception: a strain from Portugal grouped with the typical strains from Angola. The typical and especially the atypical populations from Africa displayed less genotype variation than the populations from Europe. The Portuguese samples exhibited the greatest genotypic heterogeneity. Distance analysis (UPGMA) revealed a statistically weak correlation between genotype and geographical origin of the C. albicans isolates.

Functional assessment of chest wall integrity after methylmethacrylate reconstruction

BACKGROUND

All patients with extensive resection of the anterolateral chest wall and the sternum followed by reconstruction with methylmethacrylate substitutes were assessed prospectively 6 months after the operation to delineate chest wall integrity with pulmonary function and cine-magnetic resonance imaging.

METHODS

Twenty-six patients underwent chest wall reconstruction by use of methylmethacrylate between 1994 and 1998 due to primary tumors in 35%, metastases in 27%, T3 lung cancer in 19%, and debridement for radionecrosis and osteomyelitis in 19% of patients. Three to eight ribs were resected and additional sternum resection was performed in 39% of patients.

RESULTS

There was no 30-day mortality. All patients were extubated after the operation without need for reintubation. Prosthesis dislocation occurred in 1 patient and infection in 2 patients during follow-up. Nineteen patients (73%) suffered no restrictions of daily activities. Clinical examination revealed normal shoulder girdle function in 77% of patients. There was no significant difference between preoperative and postoperative FEV1 (forced expiratory volume in 1 second) measurements in patients with lobectomy or wedge resections. Cinemagnetic resonance imaging revealed concordant chest wall movements during respiration in 92% of patients without paradoxical movements or implant dislocations being observed.

CONCLUSIONS

Large defects of the anterolateral chest wall and sternum can be reconstructed efficiently with methylmethacrylate substitutes with minimal morbidity and excellent cosmetic and functional outcome.

Genetic cholestasis: lessons from the molecular physiology of bile formation

Progressive familial intrahepatic cholestasis (PFIC) is a group of severe genetic cholestatic liver diseases of early life. PFIC types 1 and 2 are characterized by cholestasis and a low to normal serum gamma-glutamyltransferase (GGT) activity, whereas in PFIC type 3, the serum GGT activity is elevated. PFIC types 1 and 2 occur due to mutations in loci at chromosome 18 and chromosome 2, respectively. The pathophysiology of PFIC type 1 is not well understood. PFIC types 2 and 3 are caused by transport defects in the liver affecting the hepatobiliary secretion of bile acids and phospholipids, respectively. Benign recurrent intrahepatic cholestasis (BRIC) is linked to a mutation in the same familial intrahepatic cholestasis 1 locus at chromosome 18. Defects of bile acid synthesis may be difficult to differentiate from these transport defects. Intrahepatic cholestasis of pregnancy (ICP) appears to be related to these cholestatic diseases. For example, heterozygosity in families with PFIC type 3 is associated with ICP, but ICP has also been reported in families with BRIC. In Dubin-Johnson syndrome there is no cholestasis; only the hepatobiliary transport of conjugated bilirubin is affected. This, therefore, is a mild disease, and patients have a normal lifespan.