401
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Grimsrud MM, Folseraas T. Pathogenesis, diagnosis and treatment of premalignant and malignant stages of cholangiocarcinoma in primary sclerosing cholangitis. Liver Int 2019; 39:2230-2237. [PMID: 31216595 DOI: 10.1111/liv.14180] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/13/2019] [Accepted: 05/31/2019] [Indexed: 12/20/2022]
Abstract
Patients with primary sclerosing cholangitis (PSC) confer a high risk of cholangiocarcinoma (CCA). The molecular mechanisms of CCA development in PSC are incompletely understood, but pro-oncogenic processes resulting from chronic biliary inflammation are presumably of central importance. Distinguishing benign from malignant biliary strictures in PSC patients is challenging and accurately diagnosing CCA in PSC often requires a multifaceted approach involving imaging, serological testing, biliary brush cytology and fluorescence in situ hybridization (FISH). Lack of early detection tools leads to a late diagnosis in the majority of cases. Surgical resection or liver transplantation represent the only curative intent treatments in PSC-CCA, but is only an option for the small subset of patients where CCA is detected at an early stage. Current palliative treatment modalities result in only a modest increase in survival. Overall, PSC-CCA carries a dismal prognosis with a 5-year survival less than 20%. Advances aiming at improving strategies for early detection, treatment and surveillance of CCA will be essential to provide better future patient care for PSC patients. Herein, we review the pathogenetic mechanisms for PSC-CCA as well as strategies for diagnosing and managing premalignant and malignant stages of CCA in PSC.
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Affiliation(s)
- Marit M Grimsrud
- Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Trine Folseraas
- Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Section for Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway
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402
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Umetsu S, Notohara K, Nakazawa T, Tsunoda T, Sogo T, Komatsu H, Tanaka A, Tazuma S, Takikawa H, Inui A, Fujisawa T. Long-term outcomes of pediatric-onset primary sclerosing cholangitis: A single-center experience in Japan. Hepatol Res 2019; 49:1386-1397. [PMID: 31408920 DOI: 10.1111/hepr.13421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/27/2019] [Accepted: 08/05/2019] [Indexed: 01/11/2023]
Abstract
AIM Primary sclerosing cholangitis (PSC) is very rare in Japan. Although a large-scale cohort study of 781 pediatric-onset PSC patients in Europe and North America showed that the 5-year survival with native liver was 88%, the long-term outcomes of pediatric-onset PSC in Japan are unknown. Here, we evaluated the clinical outcomes of pediatric-onset PSC in Japan. METHODS We carried out a retrospective cohort study with a medical records review of pediatric PSC patients diagnosed between 1986 and 2017 at a single center. The PSC diagnoses were based on cholangiography, liver histology, and biochemical findings. The patients' survival was analyzed using the Kaplan-Meier method. Prognostic factors were determined by univariate and multivariate analyses using the Cox proportional hazards regression model. RESULTS We identified 39 pediatric-onset PSC patients (22 boys, 17 girls). The median age at diagnosis was 9 years (interquartile range 6.0-13.5 years). The median follow-up period was 5.5 years (interquartile range 3.4-8.7 years). The phenotypes of PSC-autoimmune hepatitis, PSC-inflammatory bowel disease, and small-duct PSC were diagnosed in 13 (33.3%), 36 out of 38 (94.8%), and three (7.7%) patients, respectively. The 5-year liver transplantation-free survival of the whole cohort was 93.5%. Nine patients underwent liver transplantation, and four of these nine cases resulted in death. Both the univariate and multivariate analyses showed that the phenotype of "PSC-autoimmune hepatitis overlap" was an independent poor prognostic factor. CONCLUSIONS The overall survival of pediatric-onset PSC in Japan was comparable to those in Western countries. The phenotype of PSC-autoimmune hepatitis was identified as a prognostic factor associated with a poorer long-term outcome.
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Affiliation(s)
- Shuichiro Umetsu
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama-shi Tobu Hospital, Yokohama, Japan.,Department of Hepatology and Gastroenterology for Growth and Health, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takahiro Nakazawa
- Department of Gastroenterology, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Tomoyuki Tsunoda
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama-shi Tobu Hospital, Yokohama, Japan
| | - Tsuyoshi Sogo
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama-shi Tobu Hospital, Yokohama, Japan
| | - Haruki Komatsu
- Department of Pediatrics, Toho University Sakura Hospital, Sakura, Japan
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Susumu Tazuma
- Department of General Medicine, Hiroshima University Graduate School of Medical Science, Programs of Applied Medicine, Clinical Pharmacotherapy, Hiroshima, Japan
| | - Hajime Takikawa
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Ayano Inui
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama-shi Tobu Hospital, Yokohama, Japan.,Department of Hepatology and Gastroenterology for Growth and Health, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Tomoo Fujisawa
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama-shi Tobu Hospital, Yokohama, Japan
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403
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Lemoinne S, Cazzagon N, El Mouhadi S, Trivedi PJ, Dohan A, Kemgang A, Ben Belkacem K, Housset C, Chretien Y, Corpechot C, Hirschfield G, Floreani A, Motta R, Gallix B, Barkun A, Barkun J, Chazouillères O, Arrivé L. Simple Magnetic Resonance Scores Associate With Outcomes of Patients With Primary Sclerosing Cholangitis. Clin Gastroenterol Hepatol 2019; 17:2785-2792.e3. [PMID: 30880273 DOI: 10.1016/j.cgh.2019.03.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/23/2019] [Accepted: 03/01/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Primary sclerosing cholangitis (PSC) has a variable, often progressive, course. Magnetic resonance cholangiography (MRC) is used in the diagnosis of PSC. Magnetic resonance risk scoring systems, called Anali without and with gadolinium, are used to predict disease progression, determined by radiologic factors. We aimed to assess the prognostic value of Anali scores in patients with PSC and validate our findings in a separate cohort. METHODS We performed a retrospective study of patients with large-duct PSC (internal cohort, 119 patients in France; external cohort, 119 patients in Canada, Italy, and the United Kingdom). All the first-available MRC results were reviewed by 2 radiologists and the Anali scores were calculated as follows: Anali without gadolinium = (1× dilatation of intrahepatic bile ducts) + (2× dysmorphy) + (1× portal hypertension); Anali with gadolinium = (1× dysmorphy) + (1× parenchymal enhancement heterogeneity). The primary end point was survival without liver transplantation or cirrhosis decompensation. The prognostic value of Anali scores was assessed by Cox regression modeling. RESULTS During a total of 549 patient-years for the internal cohort and 497 patient-years for the external cohort, we recorded 2 and 8 liver transplantations, 4 and 3 liver-related deaths, and 26 and 25 cirrhosis decompensations, respectively. In the univariate analysis, factors associated with survival without liver transplantation or cirrhosis decompensation in the internal cohort were as follows: serum levels of bilirubin, aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, alkaline phosphatase, albumin, and Anali scores. Anali scores without and with gadolinium identified patients' survival without liver transplantation or cirrhosis decompensation with a c-statistic of 0.89 (95% CI, 0.84-0.95) and 0.75 (95% CI, 0.64-0.87), respectively. Independent prognostic factors identified by multivariate analysis were Anali scores and bilirubinemia. The prognostic value of Anali scores was confirmed in the external cohort. CONCLUSIONS In internal and external cohorts, we found that Anali scores, determined from MRC, were associated with outcomes of patients with PSC. These scores might be used as prognostic factors.
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Affiliation(s)
- Sara Lemoinne
- Assistance Publique - Hôpitaux de Paris, Sorbonne University, INSERM, Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis & Saint-Antoine Research Center, Saint-Antoine Hospital, Paris, France
| | - Nora Cazzagon
- Assistance Publique - Hôpitaux de Paris, Sorbonne University, INSERM, Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis & Saint-Antoine Research Center, Saint-Antoine Hospital, Paris, France; Department of Surgery, Oncology and Gastroenterology - DISCOG, Padova, Italy.
| | - Sanaâ El Mouhadi
- Assistance Publique - Hôpitaux de Paris, Sorbonne University, Department of Radiology, Saint-Antoine Hospital, Paris, France
| | - Palak J Trivedi
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Center, University Hospitals Birmingham and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom; Institute of Applied Health Research, University of Birmingham, United Kingdom
| | - Anthony Dohan
- Department of Radiology, Montreal, Quebec, Canada; Assistance Publique - Hôpitaux de Paris, Department of Radiology, Hôpital Cochin, Université Sorbonne Paris Cité, Paris-Descartes, Paris, France
| | - Astrid Kemgang
- Assistance Publique - Hôpitaux de Paris, Sorbonne University, INSERM, Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis & Saint-Antoine Research Center, Saint-Antoine Hospital, Paris, France
| | - Karima Ben Belkacem
- Assistance Publique - Hôpitaux de Paris, Sorbonne University, INSERM, Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis & Saint-Antoine Research Center, Saint-Antoine Hospital, Paris, France
| | - Chantal Housset
- Assistance Publique - Hôpitaux de Paris, Sorbonne University, INSERM, Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis & Saint-Antoine Research Center, Saint-Antoine Hospital, Paris, France
| | - Yves Chretien
- Assistance Publique - Hôpitaux de Paris, Sorbonne University, INSERM, Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis & Saint-Antoine Research Center, Saint-Antoine Hospital, Paris, France
| | - Christophe Corpechot
- Assistance Publique - Hôpitaux de Paris, Sorbonne University, INSERM, Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis & Saint-Antoine Research Center, Saint-Antoine Hospital, Paris, France
| | - Gideon Hirschfield
- Institute of Applied Health Research, University of Birmingham, United Kingdom; Toronto Center for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology - DISCOG, Padova, Italy
| | - Raffaella Motta
- Department of Medicine (DIMED), Institute of Radiology, University of Padova, Padova, Italy
| | | | - Alan Barkun
- Department of Gastroenterology, Montreal, Quebec, Canada
| | - Jeffrey Barkun
- Department of Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - Olivier Chazouillères
- Assistance Publique - Hôpitaux de Paris, Sorbonne University, INSERM, Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis & Saint-Antoine Research Center, Saint-Antoine Hospital, Paris, France
| | - Lionel Arrivé
- Assistance Publique - Hôpitaux de Paris, Sorbonne University, Department of Radiology, Saint-Antoine Hospital, Paris, France
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404
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Rupp C, Hippchen T, Bruckner T, Klöters-Plachky P, Schaible A, Koschny R, Stiehl A, Gotthardt DN, Sauer P. Effect of scheduled endoscopic dilatation of dominant strictures on outcome in patients with primary sclerosing cholangitis. Gut 2019; 68:2170-2178. [PMID: 30910856 PMCID: PMC6872453 DOI: 10.1136/gutjnl-2018-316801] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 02/16/2019] [Accepted: 03/08/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Scheduled endoscopic dilatation of dominant strictures (DS) in primary sclerosing cholangitis (PSC) might improve outcome relative to endoscopic treatment on demand, but evidence is limited. Since randomisation is difficult in clinical practice, we present a large retrospective study comparing scheduled versus on-demand endoscopic retrograde cholangiopancreatography (ERCP) based on patient preferences. DESIGN Between 1987 and 2017, all new patients with PSC had been offered scheduled ERCP with dilatation of a DS if diagnosed; the latter was repeated at defined intervals until morphological resolution, independent of clinical symptoms (treatment group). Patients who refused participation were clinically evaluated annually and received endoscopic treatment only on demand (control group). The primary clinical endpoint was transplantation-free survival. Secondary outcomes were overall survival, bacterial cholangitis episodes, hepatic decompensation of liver cirrhosis and endoscopy-related adverse events. RESULTS The final study included 286 patients, 133 (46.5%) receiving scheduled ERCP and 153 (53.5%) receiving on-demand ERCP. After a mean follow-up of 9.9 years, the rate of transplantation-free survival was higher in patients receiving scheduled ERCP (51% vs 29.3%; p<0.001), as was transplantation-free survival time (median: 17.9 vs 15.2 years; log-rank: p=0.008). However, the benefit of scheduled ERCP was significant only in patients with the initial (17.1%) or later (45.5%) diagnosis of a DS (17.8 vs 11.1 years; log-rank: p<0.001). IBD (p=0.03), DS (p=0.006), higher Mayo Risk Score (p=0.02) and non-adherence to scheduled endoscopy (p=0.005) were independently associated with transplantation-free survival. CONCLUSION In our large retrospective study, regular ERCP with endoscopic balloon dilatation significantly benefits patients with PSC with DS, diagnosed both at initial presentation and during surveillance, even if asymptomatic. Further studies have to find out how to best identify stricture patients non-invasively.
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Affiliation(s)
- Christian Rupp
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany,Department of Internal Medicine IV, Interdisciplinary Endoscopy Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Theresa Hippchen
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Petra Klöters-Plachky
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
| | - Anja Schaible
- Department of General, Visceral and Transplantation Surgery, Interdisciplinary Endoscopy Center, University Hospital of Heidelberg, Heidelberg, Germany
| | - Ronald Koschny
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany,Department of Internal Medicine IV, Interdisciplinary Endoscopy Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Adolf Stiehl
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
| | - Daniel Nils Gotthardt
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany
| | - Peter Sauer
- Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany,Department of Internal Medicine IV, Interdisciplinary Endoscopy Center, University Hospital Heidelberg, Heidelberg, Germany
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405
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The Complementary Value of Magnetic Resonance Imaging and Vibration-Controlled Transient Elastography for Risk Stratification in Primary Sclerosing Cholangitis. Am J Gastroenterol 2019; 114:1878-1885. [PMID: 31738286 DOI: 10.14309/ajg.0000000000000461] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Magnetic resonance (MR) risk scores and liver stiffness (LS) have individually been shown to predict clinical outcomes in primary sclerosing cholangitis (PSC). The aim of this study was to assess their complementary prognostic value. METHODS Patients with PSC from 3 European centers with a 3-dimensional MR cholangiography available for central reviewing and a valid LS measurement assessed by vibration-controlled transient elastography by FibroScan performed within a 6-month interval were included in a longitudinal retrospective study. The MR score (Anali) without gadolinium (Gd) was calculated according to the formula: (1 × dilatation of intrahepatic bile ducts) + (2 × dysmorphy) + (1 × portal hypertension). The primary end point was survival without liver transplantation or cirrhosis decompensation. The prognostic values of LS and Anali score without Gd were assessed using Cox proportional hazard models. RESULTS One hundred sixty-two patients were included. Over a total follow-up of 753 patient-years, 40 patients experienced an adverse outcome (4 liver transplantations, 6 liver-related deaths, and 30 cirrhosis decompensations). LS and Anali score without Gd were significantly correlated (ρ = 0.51, P < 0.001) and were independently associated with the occurrence of an adverse outcome. Optimal prognostic thresholds were 10.5 kPa for LS and 2 for the Anali score without Gd. Hazard ratios (95% confidence interval) were 2.07 (1.06-4.06) and 3.78 (1.67-8.59), respectively. The use in combination of these 2 thresholds allowed us to separate patients into low-, medium-, and high-risk groups for developing adverse outcomes. The 5-year cumulative rates of adverse outcome in these 3 groups were 8%, 16%, and 38% (P < 0.001), respectively. DISCUSSION The combined use of MRI and vibration-controlled transient elastography permits easy risk stratification of patients with PSC.
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406
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Tanaka A, Kono H, Leung PSC, Gershwin ME. Recurrence of disease following organ transplantation in autoimmune liver disease and systemic lupus erythematosus. Cell Immunol 2019; 347:104021. [PMID: 31767117 DOI: 10.1016/j.cellimm.2019.104021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/01/2019] [Accepted: 11/15/2019] [Indexed: 12/15/2022]
Abstract
Disease recurrence after organ transplantation associated with graft failure is a major clinical challenge in autoimmune diseases. Primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC) and autoimmune Hepatitis (AIH) are the three most common (autoimmune liver diseases) ALD for which liver transplantation (LT) is the most effective treatment option for patients with end-stage diseases. Although the 5- and 10-year survival rates of post-LT patients are remarkable (80-84% and 71-79% in PBC, 73-87% and 58-83% in PSC, 76-79% and 67-77% respectively in AIH patients), post-LT disease recurrence is not uncommon. Here, we summarize literature findings on disease recurrence of these ALD with emphasis on the incidence, risk factors and impact on long-term outcome. We noted that the incidence of disease recurrence varies between studies, which ranges from 53% to 10.9% in PBC, 8.2% to 44.7% in PSC and 7% to 42% in AIH. The variations are likely due to differences in study design, such as sample size, duration of studies and follow up time. This is further compounded by the lack of precise clinical diagnosis criteria and biomarkers of disease recurrence in these ALD, variation in post-LT treatment protocols to prevent disease recurrence and a multitude of risk factors associated with these ALD. While recurrence of PBC and AIH does not significantly impact long term outcome including overall survival, recurrent PSC patients often require another LT. Renal transplantation, like LT, is the treatment of choice in patients with end-stage lupus nephritis. While calcineurin inhibitor (CNI) and immunosuppressive drugs have improved the survival rate, post-transplant recurrence of lupus nephritis from surveillance-biopsy proven lupus nephritis range from 30% to 44%. On the other hand, recurrence of post-transplant lupus nephritis from registry survey analysis were only 1.1% to 2.4%. In general, risk factors associated with an increased frequency of post-transplant recurrence of autoimmune diseases are not clearly defined. Large scale multi-center studies are needed to further define guidelines for the diagnosis and clinical management to minimize disease recurrence and improve outcomes of post-transplant patients.
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Affiliation(s)
- Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Hajime Kono
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Patrick S C Leung
- Division of Rheumatology Allergy and Clinical Immunology, University of California School of Medicine, Davis, CA, United States
| | - M Eric Gershwin
- Division of Rheumatology Allergy and Clinical Immunology, University of California School of Medicine, Davis, CA, United States.
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407
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Pellicano C, Leodori G, Innocenti GP, Gigante A, Rosato E. Microbiome, Autoimmune Diseases and HIV Infection: Friends or Foes? Nutrients 2019; 11:E2629. [PMID: 31684052 PMCID: PMC6893726 DOI: 10.3390/nu11112629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/25/2019] [Accepted: 10/30/2019] [Indexed: 02/07/2023] Open
Abstract
Several studies highlighted the importance of the interaction between microbiota and the immune system in the development and maintenance of the homeostasis of the human organism. Dysbiosis is associated with proinflammatory and pathological state-like metabolic diseases, autoimmune diseases and HIV infection. In this review, we discuss the current understanding of the possible role of dysbiosis in triggering and/or exacerbating symptoms of autoimmune diseases and HIV infection. There are no data about the influence of the microbiome on the development of autoimmune diseases during HIV infection. We can hypothesize that untreated patients may be more susceptible to the development of autoimmune diseases, due to the presence of dysbiosis. Eubiosis, re-established by probiotic administration, can be used to reduce triggers for autoimmune diseases in untreated HIV patients, although clinical studies are needed to evaluate the role of the microbiome in autoimmune diseases in HIV patients.
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Affiliation(s)
- Chiara Pellicano
- Department of Translational and Precision Medicine-Scleroderma Unit, Sapienza University of Rome, 00185 Rome, Italy.
| | - Giorgia Leodori
- Department of Translational and Precision Medicine-Scleroderma Unit, Sapienza University of Rome, 00185 Rome, Italy.
| | | | - Antonietta Gigante
- Department of Translational and Precision Medicine-Scleroderma Unit, Sapienza University of Rome, 00185 Rome, Italy.
| | - Edoardo Rosato
- Department of Translational and Precision Medicine-Scleroderma Unit, Sapienza University of Rome, 00185 Rome, Italy.
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408
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Goet JC, Floreani A, Verhelst X, Cazzagon N, Perini L, Lammers WJ, de Vries AC, van der Meer AJ, van Buuren HR, Hansen BE. Validation, clinical utility and limitations of the Amsterdam-Oxford model for primary sclerosing cholangitis. J Hepatol 2019; 71:992-999. [PMID: 31278949 DOI: 10.1016/j.jhep.2019.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 05/20/2019] [Accepted: 06/19/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Recently the Amsterdam-Oxford model (AOM) was introduced as a prognostic model to assess the risk of death and/or liver transplantation (LT) in primary sclerosing cholangitis (PSC). We aimed to validate and assess the utility of the AOM. METHODS Clinical and laboratory data were collected from the time of PSC diagnosis until the last visit or time of LT or death. The AOM was calculated at yearly intervals following PSC diagnosis. Discriminatory performance was assessed by calculation of the C-statistic and prediction accuracy by comparing the predicted survival with the observed survival in Kaplan-Meier estimates. A grid search was performed to identify the most discriminatory AOM threshold. RESULTS A total of 534 patients with PSC and a mean (SD) age of 39.2 (13.1) years were included. The diagnosis was large duct PSC in 466 (87%), PSC with features of autoimmune hepatitis in 52 (10%) and small-duct PSC in 16 (3%). During the median (IQR) follow-up of 7.8 (4.0-12.6) years, 167 patients underwent LT and 65 died. The median LT-free survival was 13.2 (11.8-14.7) years. The C-statistic of the AOM ranged from 0.67 at baseline to 0.75 at 5 years of follow-up. The difference between the predicted and observed survival ranged from -1.6% at 1 year to + 3.9% at 5 years of follow-up. Patients that developed AOM scores >2.0 were at significant risk of LT or death (time-dependent hazard ratio 4.09; 95% CI 2.99-5.61). CONCLUSIONS In this large cohort of patients with PSC, the AOM showed an adequate discriminative performance and good prediction accuracy at PSC diagnosis and during follow-up. This study further validates the AOM as a valuable risk stratification tool in PSC and extends its utility. LAY SUMMARY In our study we assessed whether the Amsterdam-Oxford model (AOM) is able to correctly estimate the risk of liver transplantation or death in patients with primary sclerosing cholangitis (PSC). This model uses 7 objective and readily available variables to estimate prognosis for individual patients at the time of PSC diagnosis. The AOM may aid in patient counselling and timing of diagnostic procedures or therapeutic interventions for complications of liver disease. We confirm that the model works well at PSC diagnosis, but also when the AOM is recalculated at different timepoints during follow-up, greatly improving the applicability of the model in clinical practice and for individual patients.
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Affiliation(s)
- Jorn C Goet
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Belgium
| | - Nora Cazzagon
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Lisa Perini
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands; Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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409
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Khoshpouri P, Habibabadi RR, Hazhirkarzar B, Ameli S, Ghadimi M, Ghasabeh MA, Menias CO, Kim A, Li Z, Kamel IR. Imaging Features of Primary Sclerosing Cholangitis: From Diagnosis to Liver Transplant Follow-up. Radiographics 2019; 39:1938-1964. [DOI: 10.1148/rg.2019180213] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Pegah Khoshpouri
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 600 N Wolfe St, MRI Room 143, Baltimore, MD 21287 (P.K., R.R.H., B.H., S.A., M.G., M.A.G., A.K., Z.L., I.R.K.); and Department of Radiology, Mayo Clinic Phoenix, Scottsdale, Ariz (C.O.M.)
| | - Roya Rezvani Habibabadi
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 600 N Wolfe St, MRI Room 143, Baltimore, MD 21287 (P.K., R.R.H., B.H., S.A., M.G., M.A.G., A.K., Z.L., I.R.K.); and Department of Radiology, Mayo Clinic Phoenix, Scottsdale, Ariz (C.O.M.)
| | - Bita Hazhirkarzar
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 600 N Wolfe St, MRI Room 143, Baltimore, MD 21287 (P.K., R.R.H., B.H., S.A., M.G., M.A.G., A.K., Z.L., I.R.K.); and Department of Radiology, Mayo Clinic Phoenix, Scottsdale, Ariz (C.O.M.)
| | - Sanaz Ameli
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 600 N Wolfe St, MRI Room 143, Baltimore, MD 21287 (P.K., R.R.H., B.H., S.A., M.G., M.A.G., A.K., Z.L., I.R.K.); and Department of Radiology, Mayo Clinic Phoenix, Scottsdale, Ariz (C.O.M.)
| | - Maryam Ghadimi
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 600 N Wolfe St, MRI Room 143, Baltimore, MD 21287 (P.K., R.R.H., B.H., S.A., M.G., M.A.G., A.K., Z.L., I.R.K.); and Department of Radiology, Mayo Clinic Phoenix, Scottsdale, Ariz (C.O.M.)
| | - Mounes Aliyari Ghasabeh
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 600 N Wolfe St, MRI Room 143, Baltimore, MD 21287 (P.K., R.R.H., B.H., S.A., M.G., M.A.G., A.K., Z.L., I.R.K.); and Department of Radiology, Mayo Clinic Phoenix, Scottsdale, Ariz (C.O.M.)
| | - Christine O. Menias
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 600 N Wolfe St, MRI Room 143, Baltimore, MD 21287 (P.K., R.R.H., B.H., S.A., M.G., M.A.G., A.K., Z.L., I.R.K.); and Department of Radiology, Mayo Clinic Phoenix, Scottsdale, Ariz (C.O.M.)
| | - Amy Kim
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 600 N Wolfe St, MRI Room 143, Baltimore, MD 21287 (P.K., R.R.H., B.H., S.A., M.G., M.A.G., A.K., Z.L., I.R.K.); and Department of Radiology, Mayo Clinic Phoenix, Scottsdale, Ariz (C.O.M.)
| | - Zhiping Li
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 600 N Wolfe St, MRI Room 143, Baltimore, MD 21287 (P.K., R.R.H., B.H., S.A., M.G., M.A.G., A.K., Z.L., I.R.K.); and Department of Radiology, Mayo Clinic Phoenix, Scottsdale, Ariz (C.O.M.)
| | - Ihab R. Kamel
- From the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 600 N Wolfe St, MRI Room 143, Baltimore, MD 21287 (P.K., R.R.H., B.H., S.A., M.G., M.A.G., A.K., Z.L., I.R.K.); and Department of Radiology, Mayo Clinic Phoenix, Scottsdale, Ariz (C.O.M.)
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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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411
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Chen YY, Arndtz K, Webb G, Corrigan M, Akiror S, Liaskou E, Woodward P, Adams DH, Weston CJ, Hirschfield GM. Intrahepatic macrophage populations in the pathophysiology of primary sclerosing cholangitis. JHEP Rep 2019; 1:369-376. [PMID: 32039388 PMCID: PMC7005651 DOI: 10.1016/j.jhepr.2019.10.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 10/05/2019] [Accepted: 10/15/2019] [Indexed: 12/11/2022] Open
Abstract
Background & Aims Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by progressive inflammatory and fibrotic injury to the biliary tree. We sought to further delineate the contribution of macrophage lineages in PSC pathobiology. Methods Human liver tissues and/or blood samples from patients with PSC, primary biliary cholangitis, other non-cholestatic/non-autoimmune diseases, including alcohol-related liver disease and non-alcoholic steatohepatitis, as well as normal liver, were sourced from our liver transplantation program. Liver fibrosis was studied using Van Gieson staining, while the frequencies of infiltrating monocyte and macrophage lineages, both in the circulation and the liver, were investigated by flow cytometry, including the expression of TGR-5, a G protein-coupled receptor (GPBAR1/TGR-5). Results Significantly higher frequencies of CD68+CD206+ macrophages were detected in the livers of patients with PSC (median 19.17%; IQR 7.25–32.8%; n = 15) compared to those of patients with other liver diseases (median 12.05%; IQR 5.61–16.03%; n = 12; p = 0.0373). CD16+ monocytes, including both intermediate (CD14+CD16++) and non-classical (CD14dimCD16++) monocytes, were preferentially recruited into chronically diseased livers, with the highest recruitment ratios in PSC (median 15.83%; IQR 9.66–29.5%; n = 15), compared to other liver diseases (median 6.66%; IQR 2.88–11.64%, n = 14, p = 0.0152). The expression of TGR-5 on CD68+ intrahepatic macrophages was increased in chronic liver disease; TGR-5 expression on intrahepatic macrophages was highest in PSC (median 36.32%; IQR 17.71–63.61%; n = 6) and most TGR-5+ macrophages were CD68+CD206+ macrophages. Conclusions Underlying a potential role for macrophages in PSC pathobiology, we demonstrate, using patient-derived tissue, increased CD16+ monocyte recruitment and a higher frequency of CD68+CD206+ macrophages in the livers of patients with PSC; the CD68+CD206+ macrophage subset was associated with significantly higher TGR-5 expression in PSC. Lay summary Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease associated with progressive inflammation of the bile duct, leading to fibrosis and end-stage liver disease. In this study we explore the role of a type of immune cell, the macrophage, in contributing to PSC as a disease, hoping that our findings direct scientists towards new treatment targets. Our findings based on human liver and blood analyses demonstrate a greater frequency of a particular subset of immune cell, the CD68+CD206+ macrophage, with significantly higher TGR-5 expression on this subset in PSC. CD68+CD206+ macrophage populations predominate in the liver tissue of patients with primary sclerosing cholangitis. Intrahepatic CD16+ monocytes preferentially accumulate in the livers of patients with primary sclerosing cholangitis. The expression of TGR-5 is increased in chronic liver disease. TGR-5 expression on CD68+CD206+ intrahepatic macrophages is higher in patients with primary sclerosing cholangitis.
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Affiliation(s)
- Yung-Yi Chen
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Kathryn Arndtz
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gwilym Webb
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Margaret Corrigan
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sarah Akiror
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Evaggelia Liaskou
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul Woodward
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
| | - David H. Adams
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chris J. Weston
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gideon M. Hirschfield
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Toronto Centre for Liver Disease, University Health Network and University of Toronto, Toronto, Canada
- Corresponding author. Address: Gideon M Hirschfield, Lily and Terry Horner Chair in Autoimmune Liver Disease Research, Toronto Centre for Liver Disease, University Health Network and Department of Medicine, University of Toronto.
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412
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Sun T, Annunziato S, Tchorz JS. Hepatic ductular reaction: a double-edged sword. Aging (Albany NY) 2019; 11:9223-9224. [PMID: 31645478 PMCID: PMC6874463 DOI: 10.18632/aging.102386] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 10/10/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Tianliang Sun
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Stefano Annunziato
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Jan S Tchorz
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, Basel, Switzerland
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413
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Cornillet M, Jansson H, Schaffer M, Hertwig L, Berglin L, Zimmer CL, Johansson H, Ellis E, Isaksson B, Gonzalez-Galarza FF, Middleton D, Malmberg KJ, Sparrelid E, Björkström NK. Imbalance of Genes Encoding Natural Killer Immunoglobulin-Like Receptors and Human Leukocyte Antigen in Patients With Biliary Cancer. Gastroenterology 2019; 157:1067-1080.e9. [PMID: 31229495 DOI: 10.1053/j.gastro.2019.06.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 06/03/2019] [Accepted: 06/16/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Bile duct tumors are rare and have poor prognoses. Natural killer (NK) cells are frequent in human liver and infiltrate these tumors but do not control their progression. Responses of NK cells are regulated by NK immunoglobulin-like receptors (KIRs), which interact with HLA class I ligands. We aimed to characterize the features of the KIR gene loci and their ligands in patients with bile duct cancer (BDC). METHODS We performed combined multidimensional characterization of genes that encode KIRs and their ligands in blood samples from patients with BDC from Sweden, followed for up to 8 years after diagnosis (n = 148), in 2 geographically matched cohorts of healthy individuals from Northern Europe (n = 204 and n = 900), and in healthy individuals from 6 geographically unrelated populations (n = 2917). We used real-time polymerase chain reaction, RNA sequencing, immunohistochemistry, and flow cytometry to evaluate NK-cell presence, as well as KIR and KIR-ligand expression in bile duct tumors and control tissues. RESULTS Patients with bile duct tumors had multiple alterations at the KIR gene loci. KIR loci are grouped into genotypes that encode more inhibitory (group A) and more activating (group B) receptors, which can be subdivided into centromeric and telomeric fragments. Patients with BDC had a lower prevalence of KIR2DL3, which was linked to disequilibrium in centromeric A/B and B/B genotypes, compared with control individuals. The associations between KIRs and KIR ligands differed between patients with BDC and control individuals; patients had an altered balance between activating and inhibitory KIRs. KIR-positive NK cells infiltrated biliary tumors that expressed matched KIR ligands. CONCLUSIONS In a multidimensional analysis of DNA from blood samples of patients with BDC in Europe, we found patients to have multiple alterations at the KIR and HLA gene loci compared with control individuals. These alterations might affect NK-cell tumor surveillance. NK cells from bile duct tumors expressed KIRs and were found in tumors that expressed cognate ligands. This should be considered in development of immune-based therapies for BDC.
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Affiliation(s)
- Martin Cornillet
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| | - Hannes Jansson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Marie Schaffer
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Laura Hertwig
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lena Berglin
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Christine L Zimmer
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Helene Johansson
- Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, and Department of Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Ewa Ellis
- Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, and Department of Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Bengt Isaksson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Faviel F Gonzalez-Galarza
- Center for Biomedical Research, Faculty of Medicine, Autonomous University of Coahuila, Torreon, Mexico
| | - Derek Middleton
- Transplant Immunology Laboratory, Royal Liverpool University Hospital, Liverpool, UK
| | - Karl-Johan Malmberg
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden; Department of Cancer Immunology, Institute for Cancer Research, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Niklas K Björkström
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
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414
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Glaser F, John C, Engel B, Höh B, Weidemann S, Dieckhoff J, Stein S, Becker N, Casar C, Schuran FA, Wieschendorf B, Preti M, Jessen F, Franke A, Carambia A, Lohse AW, Ittrich H, Herkel J, Heeren J, Schramm C, Schwinge D. Liver infiltrating T cells regulate bile acid metabolism in experimental cholangitis. J Hepatol 2019; 71:783-792. [PMID: 31207266 DOI: 10.1016/j.jhep.2019.05.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS T cells are central mediators of liver inflammation and represent potential treatment targets in cholestatic liver disease. Whereas emerging evidence shows that bile acids (BAs) affect T cell function, the role of T cells for the regulation of BA metabolism is unknown. In order to understand this interplay, we investigated the influence of T cells on BA metabolism in a novel mouse model of cholangitis. METHODS Mdr2-/- mice were crossed with transgenic K14-OVAp mice, which express an MHC class I restricted ovalbumin peptide on biliary epithelial cells (Mdr2-/-xK14-OVAp). T cell-mediated cholangitis was induced by the adoptive transfer of antigen-specific CD8+ T cells. BA levels were quantified using a targeted liquid chromatography-mass spectrometry-based approach. RESULTS T cell-induced cholangitis resulted in reduced levels of unconjugated BAs in the liver and significantly increased serum and hepatic levels of conjugated BAs. Genes responsible for BA synthesis and uptake were downregulated and expression of the bile salt export pump was increased. The transferred antigen-specific CD8+ T cells alone were able to induce these changes, as demonstrated using Mdr2-/-xK14-OVAp recipient mice on the Rag1-/- background. Mechanistically, we showed by depletion experiments that alterations in BA metabolism were partly mediated by the proinflammatory cytokines TNF and IFN-γ in an FXR-dependent manner, a process that in vitro required cell contact between T cells and hepatocytes. CONCLUSION Whereas it is known that BA metabolism is dysregulated in sepsis and related conditions, we have shown that T cells are able to control the synthesis and metabolism of BAs, a process which depends on TNF and IFN-γ. Understanding the effect of lymphocytes on BA metabolism will help in the design of combined treatment strategies for cholestatic liver diseases. LAY SUMMARY Dysregulation of bile acid metabolism and T cells can contribute to the development of cholangiopathies. Before targeting T cells for the treatment of cholangiopathies, it should be determined whether they exert protective effects on bile acid metabolism. Herein, we demonstrate that T cell-induced cholangitis resulted in decreased levels of harmful unconjugated bile acids. T cells were able to directly control synthesis and metabolism of bile acids, a process which was dependent on the proinflammatory cytokines TNF and IFN-γ. Understanding the effect of lymphocytes on bile acid metabolism will help in the design of combined treatment strategies for cholestatic liver diseases.
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Affiliation(s)
- Fabian Glaser
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Clara John
- Department of Biochemistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Engel
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benedikt Höh
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sören Weidemann
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Dieckhoff
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stephanie Stein
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nathalie Becker
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Casar
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fenja Amrei Schuran
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Björn Wieschendorf
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Max Preti
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Jessen
- Department of Biochemistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Franke
- Institute of Clinical Molecular Biology, Christian-Albrechts-University, Kiel, Germany
| | - Antonella Carambia
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Harald Ittrich
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Herkel
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joerg Heeren
- Department of Biochemistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Schramm
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Centre for Rare Diseases, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.
| | - Dorothee Schwinge
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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415
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Caron B, Peyrin-Biroulet L, Pariente B, Bouhnik Y, Seksik P, Bouguen G, Caillo L, Laharie D, Carbonnel F, Altwegg R, Reenaers C, Serrero M, Trang-Poisson C, Nancey S, Filippi J, Abitbol V, Savoye G, Vuitton L, Viennot S, Fumery M, Reymond M, Bronowicki JP, Reimund JM, Amiot A. Vedolizumab Therapy is Ineffective for Primary Sclerosing Cholangitis in Patients With Inflammatory Bowel Disease: A GETAID Multicentre Cohort Study. J Crohns Colitis 2019; 13:1239-1247. [PMID: 31056693 DOI: 10.1093/ecco-jcc/jjz088] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Whether vedolizumab may be effective as a treatment for primary sclerosing cholangitis [PSC] in patients with inflammatory bowel disease [IBD] remains controversial. METHODS We performed a retrospective observational study of consecutive patients with IBD and PSC, treated with vedolizumab for at least 30 weeks in 22 centres of GETAID from January 2015 to June 2016. The outcomes included a decrease in the serum alkaline phosphatase [ALP] concentration of at least 50% from baseline to Week 30 or 54, a change in any serum liver enzymes concentrations, and an assessment of the efficacy and safety of vedolizumab in IBD. RESULTS Among 75 patients with active IBD and PSC treated with vedolizumab, 21 patients discontinued vedolizumab before Week 30 [due to lack of efficacy in 19 and malignancy in two patients]. In the remaining 54 patients, a decrease in the serum ALP concentration of at least 50% from baseline to Weeks 30 and 54 was observed in four [7%] and four [11%] patients, respectively. No significant change was observed in serum liver enzyme concentrations at week 30 or 54. After a median follow-up period of 19.4 [14.0-29.9] months, nine cases of digestive neoplasia [colorectal neoplasia in seven and cholangiocarcinoma in two] were reported. CONCLUSIONS In patients with IBD and PSC, vedolizumab did not improve serum liver enzyme concentrations at week 30 or 54. Nine cases of digestive cancer occurred during the follow-up period, confirming the need for a tight surveillance programme in this population.
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Affiliation(s)
- Benedicte Caron
- Department of Gastroenterology, Hôpitaux Universitaires de Strasbourg [Hôpital de Hautepierre] and INSERM U1113 IRFAC, Université de Strasbourg [Faculté de Médecine], Strasbourg, France
| | | | - Benjamin Pariente
- Department of Gastroenterology, Huriez Hospital, Université of Lille, Lille, France
| | - Yoram Bouhnik
- Department of Gastroenterology, IBD and Nutrition Support, Beaujon Hospital, University Paris 7 Denis Diderot, Clichy, France
| | - Philippe Seksik
- Department of Gastroenterology, AP-HP, Hôpital Saint-Antoine, ERL 1057 INSERM/UMRS 7203, UPMC Université Paris 6, Paris, France
| | - Guillaume Bouguen
- Department of Gastroenterology, Pontchaillou Hospital and Rennes University, Rennes, France
| | - Ludovic Caillo
- Department of Gastroenterology, Nimes University Hospital, Nimes, France
| | - David Laharie
- Department of Hepato-Gastroenterology, University Hospital of Bordeaux, Hôpital Haut-Lévêque, Bordeaux, France
| | - Franck Carbonnel
- Department of Gastroenterology, Bicetre University Hospital, APHP, Université Paris Sud, le Kremlin Bicêtre, Paris, France
| | - Romain Altwegg
- Department of Gastroenterology, Hôpital Saint-Eloi, University Hospital of Montpellier, Montpellier, France
| | - Catherine Reenaers
- Department of Gastroenterology, Liege University Hospital, Liege, Belgium
| | - Melanie Serrero
- Hôpital Nord, Centre d'investigation clinique Marseille Nord, Université Méditerranée, Marseille, France
| | - Caroline Trang-Poisson
- Department of Gastroenterology, Institut des Maladies de l'appareil Digestif [IMAD], University Hospital of Nantes, Nantes University, Nantes, France
| | - Stephane Nancey
- Department of Gastroenterology, Hospices Civils de Lyon and University Claude Bernard Lyon 1, Pierre-Benite, France
| | - Jerome Filippi
- Department of Gastroenterology and Clinical Nutrition, Nice University Hospital, University of Nice Sophia-Antipolis, Nice, France
| | - Vered Abitbol
- Department of Gastroenterology, Cochin Hospital, University Paris 5 Descartes, Paris, France
| | - Guillaume Savoye
- Department of Gastroenterology, Rouen University and Hospital, Rouen, France
| | - Lucine Vuitton
- Department of Gastroenterology, Besançon University Hospital, Besançon, France
| | - Stephanie Viennot
- Department of Gastroenterology, Caen University Hospital, Caen, France
| | - Mathurin Fumery
- Department of Gastroenterology, Amiens University Hospital, Amiens, France
| | - Maud Reymond
- Department of Hepato-Gastroenterology, University Hospital Estaing of Clermont-Ferrand, Université d'Auvergne, Clermont-Ferrand, France
| | | | - Jean-Marie Reimund
- Department of Gastroenterology, Hôpitaux Universitaires de Strasbourg [Hôpital de Hautepierre] and INSERM U1113 IRFAC, Université de Strasbourg [Faculté de Médecine], Strasbourg, France
| | - Aurelien Amiot
- Department of Gastroenterology, Henri Mondor Hospital, APHP, EC2M3-EA7375, Paris Est-Créteil Val de Marne University, Creteil, France
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416
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Sundaram S, Jearth V. Primary Sclerosing Cholangitis: A Clinical Update. EUROPEAN MEDICAL JOURNAL 2019. [DOI: 10.33590/emj/10313809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Primary sclerosing cholangitis (PSC) is a rare cholestatic disorder of the liver, with strictures in the bile ducts leading to cirrhosis of the liver in a proportion of patients. PSC is commonly associated with inflammatory bowel disease and increased risk of cholangiocarcinoma, gall bladder cancer, colorectal cancer, and hepatocellular carcinoma. Medical therapies are primarily aimed at symptom management and disease-modifying therapies are limited. Endoscopic therapies are used in patients with dominant strictures and liver transplantation is a last resort. In this article, the authors aim to comprehensively review the epidemiology, diagnosis, and management of PSC with emphasis on risk of malignancies and management of PSC. The authors also survey the advances in pathogenesis understanding and novel medical therapies for PSC.
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Affiliation(s)
- Sridhar Sundaram
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Vaneet Jearth
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Centre, Mumbai, India
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417
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Quraishi MN, Shaheen WA. Editorial: gut microbial profile associated with primary sclerosing cholangitis-what is new and how do we progress from here? Aliment Pharmacol Ther 2019; 50:605-606. [PMID: 31414544 DOI: 10.1111/apt.15424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Mohammed Nabil Quraishi
- University of Birmingham Microbiome Treatment Centre, University of Birmingham, Birmingham, UK.,Department of Gastroenterology, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Walaa A Shaheen
- University of Birmingham Microbiome Treatment Centre, University of Birmingham, Birmingham, UK
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418
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Joosse ME, Haisma SM, Sterk MFM, van Munster KN, Ponsioen CIJ, Houwen RHJ, Koot BGP, de Meij T, van Rheenen PF, de Koning BAE. Disease progression in paediatric- and adult-onset sclerosing cholangitis: Results from two independent Dutch registries. Liver Int 2019; 39:1768-1775. [PMID: 31152478 DOI: 10.1111/liv.14159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/15/2019] [Accepted: 05/20/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Sclerosing cholangitis (SC) is a severe liver disease leading to destruction of bile ducts. It is believed to run a milder course in children than in adults. To test this assumption, we evaluated time-to-complication curves in two independent paediatric-onset cohorts from the same geographical area. METHODS Short-term disease outcomes were evaluated with an online clinical registry that was filled with data on children with SC diagnosed between 2000 and 2017 and who were followed bi-annually thereafter. Long-term disease outcomes were evaluated in a paediatric-onset subcohort derived from a previously published population-based study from the Netherlands. Time-to-complication in the first cohort was defined as the time from diagnosis until portal hypertension, biliary obstructions and infections, development of malignancy, or liver transplantation, whichever came first. In the second cohort time-to-complication was defined as the time until liver transplantation or PSC-related death. RESULTS Median age at diagnosis in the first cohort (n = 86) was 12.3 years. In the first 5 years post-diagnosis 23% of patients developed complications. The patients in the population-based study (n = 683) were stratified into those diagnosed before the age of 18 years ('paediatric-onset' subcohort, n = 43) and those diagnosed after the age of 18 years ('adult-onset' subcohort, n = 640). Median age at diagnosis was 14.6 and 40.2 years, respectively. Median time-to-complication in the paediatric-onset and adult-onset subcohorts was not statistically different. CONCLUSION Paediatric and adult-onset SC run a similar long-term disease course. Paediatricians who treat children with SC should monitor them closely to recognize early complications and control long-term sequelae.
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Affiliation(s)
- Maria E Joosse
- Department of Pediatric Gastroenterology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sjoukje M Haisma
- University of Groningen, University Medical Center Groningen, Pediatric Gastroenterology Hepatology and Nutrition, Groningen, the Netherlands
| | - Marlou F M Sterk
- Department of Pediatric Gastroenterology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Kim N van Munster
- Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Cyriel I J Ponsioen
- Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roderick H J Houwen
- Department of Pediatric Gastroenterology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bart G P Koot
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Tim de Meij
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Pediatric Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
| | - Patrick F van Rheenen
- University of Groningen, University Medical Center Groningen, Pediatric Gastroenterology Hepatology and Nutrition, Groningen, the Netherlands
| | - Barbara A E de Koning
- Department of Pediatric Gastroenterology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
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419
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Rühlemann M, Liwinski T, Heinsen F, Bang C, Zenouzi R, Kummen M, Thingholm L, Tempel M, Lieb W, Karlsen T, Lohse A, Hov J, Denk G, Lammert F, Krawczyk M, Schramm C, Franke A. Consistent alterations in faecal microbiomes of patients with primary sclerosing cholangitis independent of associated colitis. Aliment Pharmacol Ther 2019; 50:580-589. [PMID: 31250469 PMCID: PMC6899739 DOI: 10.1111/apt.15375] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 02/26/2019] [Accepted: 05/24/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Single-centre studies reported alterations of faecal microbiota in patients with primary sclerosing cholangitis (PSC). As regional factors may affect microbial communities, it is unclear if a microbial signature of PSC exists across different geographical regions. AIM To identify a robust microbial signature of PSC independent of geography and environmental influences. METHODS We included 388 individuals (median age, 47 years; range, 15-78) from Germany and Norway in the study, 137 patients with PSC (n = 75 with colitis), 118 with ulcerative colitis (UC) and 133 healthy controls. Faecal microbiomes were analysed by 16S rRNA gene sequencing (V1-V2). Differences in relative abundances of single taxa were subjected to a meta-analysis. RESULTS In both cohorts, microbiota composition (beta-diversity) differed between PSC patients and controls (P < 0.001). Random forests classification discriminated PSC patients from controls in both geographical cohorts with an average area under the curve of 0.88. Compared to healthy controls, many new cohort-spanning alterations were identified in PSC, such as an increase of Proteobacteria and the bile-tolerant genus Parabacteroides, which were detected independent from geographical region. Associated colitis only had minor effects on microbiota composition, suggesting that PSC itself drives the faecal microbiota changes observed. CONCLUSION Compared to healthy controls, numerous microbiota alterations are reproducible in PSC patients across geographical regions, clearly pointing towards a microbiota composition that is shaped by the disease itself and not by environmental factors. These reproducibly altered microbial populations might provide future insights into the pathophysiology of PSC.
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420
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Khoshpouri P, Hazhirkarzar B, Ameli S, Pandey A, Ghadimi M, Rezvani Habibabadi R, Aliyari Ghasabeh M, Pandey P, Shaghaghi M, Kamel I. Quantitative spleen and liver volume changes predict survival of patients with primary sclerosing cholangitis. Clin Radiol 2019; 74:734.e13-734.e20. [DOI: 10.1016/j.crad.2019.05.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/20/2019] [Indexed: 01/01/2023]
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421
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Hippchen T, Sauer P, Göppert B, Schirmacher P, Gotthardt DN, Weiss KH, Stremmel W, Rupp C. Association between serum IgG level and clinical course in primary sclerosing cholangitis. BMC Gastroenterol 2019; 19:153. [PMID: 31455255 PMCID: PMC6712727 DOI: 10.1186/s12876-019-1075-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 08/20/2019] [Indexed: 12/19/2022] Open
Abstract
Background Primary sclerosing cholangitis is a chronic cholestatic liver disease. The pathomechanism is still not fully understood, but there is evidence that immune-mediated processes may contribute to disease progression. Methods We studied the prognostic relevance of serum immunoglobulin G (IgG) elevated above the upper limit of normal as a marker for immune activation at initial diagnosis and its influence on transplantation-free survival in a well-defined cohort of PSC patients. Results The final study cohort comprises of 148 PSC patients. Elevated IgG levels were found in 66 patients (44.6%). Apart from their younger age at first diagnosis, there was no significant difference between patients with or without elevated IgG levels. The presence of a concomitant inflammatory bowel disease, an autoimmune hepatitis or immunosuppressive medication was equally distributed between both groups. Patients with elevated IgG levels reached the combined endpoint (34 (59.6%) vs. 23 (40.4%); p = 0.004) significantly more often and had reduced transplantation-free survival (Log-rank: 24.0 (10.2–37.9) vs. 14.0 (8.5–19.5); p < 0.05). Cox regression analysis including age, gender, presence of IBD, presence of dominant stricture (DS), Mayo Risk Score (MRS), immunosuppression, biochemical response to UDCA and elevated IgG-levels confirmed MRS (p = 0.03), DS (p = 0.04), biochemical response (p = 0.04) and elevated IgG level (p = 0.04) as independent risk factors for reduced transplantation-free survival. Conclusion We identified elevated serum IgG levels at first diagnosis as an independent risk factor for reduced transplant free-survival in patients with PSC.
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Affiliation(s)
- Theresa Hippchen
- Department of Internal Medicine IV, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Peter Sauer
- Department of Internal Medicine IV, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Benjamin Göppert
- Institute of Pathology, University of Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
| | - Peter Schirmacher
- Institute of Pathology, University of Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
| | - Daniel Nils Gotthardt
- Department of Internal Medicine IV, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Karl-Heinz Weiss
- Department of Internal Medicine IV, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Wolfgang Stremmel
- Department of Internal Medicine IV, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Christian Rupp
- Department of Internal Medicine IV, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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422
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Cazzagon N, Chazouillères O, Corpechot C, El Mouhadi S, Chambenois E, Desaint B, Chaput U, Lemoinne S, Arrivé L. Predictive criteria of response to endoscopic treatment for severe strictures in primary sclerosing cholangitis. Clin Res Hepatol Gastroenterol 2019; 43:387-394. [PMID: 30772328 DOI: 10.1016/j.clinre.2019.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/17/2018] [Accepted: 01/10/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to identify predictive criteria of improvement after endoscopic treatment (ET) for severe strictures of extrahepatic bile ducts in patients with primary sclerosing cholangitis (PSC). METHODS PSC patients who had at least one ET for severe stricture were included. Features of magnetic resonance cholangiography (MRC), performed before ET, were evaluated according to a standard model of interpretation, and a radiologic qualitative score of probability of improvement after ET was built. Score 3 (likely) was given in case of severe common bile duct (CBD) stricture with marked dilatation without severe strictures of upstream ducts, Score 1 (unlikely) was given in case of severe multiple strictures of secondary ducts without biliary dilatation and Score 2 (undeterminate) was given to an intermediate pattern. The response to ET was assessed at 2 months (T2-response) from the last ET and at 12 months (T12-response) from inclusion. RESULTS Thirty-one patients were included. All had severe stricture (reduction ≥ 75% of the diameter) of CBD and 50% had severe stricture of right and/or left hepatic duct (LHD) at MRC before ET. According to the qualitative score, 16 patients had Score 3, 7 had Score 1 and 9 had Score 2. T12-response was obtained in 50% of patients. In univariate analysis, short LHD strictures, bilirubin, transaminases, pruritus and Score 3 were associated with T12-response. Increased bilirubin and transaminases were independent predictive factors of T12-response (HR 24, 95% CI: 3.4-170.4, P = 0.001 and 23.8, 95% CI: 3.4-169.4, P = 0.002, respectively). CONCLUSION MRC, together with biochemical features, may contribute to identify the PSC patients who are likely to be improved after ET for severe strictures of extrahepatic bile ducts.
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Affiliation(s)
- Nora Cazzagon
- Reference center for inflammatory biliary disease and autoimmune hepatitis (MIVB), Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, 75012 Paris, France; Department of Surgery, Oncology and Gastroenterology (DiSCOG), University of Padova, Padova, Italy
| | - Olivier Chazouillères
- Reference center for inflammatory biliary disease and autoimmune hepatitis (MIVB), Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, 75012 Paris, France
| | - Christophe Corpechot
- Reference center for inflammatory biliary disease and autoimmune hepatitis (MIVB), Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, 75012 Paris, France
| | - Sanaâ El Mouhadi
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris AP-HP, Sorbonne university, 75012 Paris, France
| | - Edouard Chambenois
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris AP-HP, Sorbonne university, 75012 Paris, France
| | - Benoit Desaint
- Reference center for inflammatory biliary disease and autoimmune hepatitis (MIVB), Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, 75012 Paris, France; Endoscopic department, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, Paris, France
| | - Ulriikka Chaput
- Reference center for inflammatory biliary disease and autoimmune hepatitis (MIVB), Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, 75012 Paris, France; Endoscopic department, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, Paris, France
| | - Sara Lemoinne
- Reference center for inflammatory biliary disease and autoimmune hepatitis (MIVB), Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, 75012 Paris, France
| | - Lionel Arrivé
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris AP-HP, Sorbonne university, 75012 Paris, France.
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423
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Abstract
Immunoglobulin (Ig)G4-related sclerosing cholangitis (IgG4-SC) is a biliary tract manifestation of IgG4-related diseases (IgG4-RD); a subgroup of SC defined as a condition with progressive stenosis and destruction of the bile ducts due to diffuse inflammation and fibrosis. IgG4-SC is clinically characterized by the (a) chronic elevation of cholestatic enzyme levels, (b) significant elevation of serum IgG4 levels, (c) diffuse or segmental narrowing of intra and/or extra hepatic bile ducts with thickening of the bile duct wall in imaging studies, (d) marked lymphoplasmacytic and IgG4-positive plasma cell infiltration and fibrosis in histology, (e) presence of IgG4-RD in other organs, mainly involving autoimmune pancreatitis, and (f) excellent response to corticosteroids. The diagnosis of IgG4-SC is based on a combination of these findings. Although the IgG4-SC diagnosis is different from that of primary sclerosing cholangitis (PSC) or biliary and pancreatic malignancies, it is extremely important to diagnose or suspect IgG4-SC appropriately; as the incorrect diagnosis of PSC or malignant diseases may lead to the progression of fibrosis in patients due to untreated chronic cholestasis, or to unnecessary major surgical resections. Although its etiology remains unclear, recent studies of IgG4-SC have attempted to clarify the roles of the IgG4 molecule and novel autoantibodies detected in patients with IgG4-SC.
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Affiliation(s)
- Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
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424
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Maurice JB, Thorburn D. Precision medicine in primary sclerosing cholangitis. J Dig Dis 2019; 20:346-356. [PMID: 31099965 DOI: 10.1111/1751-2980.12788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/07/2019] [Indexed: 12/11/2022]
Abstract
Primary sclerosing cholangitis is a rare, complex autoimmune disease in relatively young patients. There is currently no treatment for the disease, resulting in high rates of advanced liver disease leading to death or liver transplantation. However, advances have been made in our understanding of the pathophysiological mechanisms of the disease, particularly from breakthroughs in the underlying genetics. Moreover, large international collaborations have generated important clinical data that have given greater detail on the different disease phenotypes and natural history, generating new risk prediction models. As a result, drug development may be designed to target specific disease mechanisms at known points of the disease natural history. Therefore, more drugs are entering phase II and III development, giving hope that soon patient-specific treatments may be available to treat this difficult disease.
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Affiliation(s)
- James B Maurice
- Department of Hepatology and Liver Transplantation, Royal Free Hospital NHS Foundation Trust, London, UK
| | - Douglas Thorburn
- Department of Hepatology and Liver Transplantation, Royal Free Hospital NHS Foundation Trust, London, UK
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425
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Manipulation of the Gut-Liver Axis Using Microbiome Restoration Therapy in Primary Sclerosing Cholangitis. Am J Gastroenterol 2019; 114:1027-1029. [PMID: 30920413 DOI: 10.14309/ajg.0000000000000191] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Alteration of the normal gut-liver axis is important in primary sclerosing cholangitis (PSC). Lack of effective medical therapy for PSC makes microbiome restoration an alluring therapeutic target. Allegretti et al. performed an open-label safety trial of fecal microbiota transplant (FMT) in noncirrhotic PSC patients with inflammatory bowel disease in remission on minimal therapy. FMT was safe in this population, and after FMT, there was a stable, early increase in microbial diversity and donor engraftment with mixed effects on alkaline phosphatase but no significant change in fecal bile acid profile. Further trials are needed to find whether FMT has a role to play in PSC therapy.
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426
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The Etiology of Pancreatic Manifestations in Patients with Inflammatory Bowel Disease. J Clin Med 2019; 8:jcm8070916. [PMID: 31247968 PMCID: PMC6679036 DOI: 10.3390/jcm8070916] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/18/2019] [Accepted: 06/21/2019] [Indexed: 02/07/2023] Open
Abstract
Inflammatory bowel disease (IBD) is an idiopathic chronic and recurrent condition that comprises Crohn's disease and ulcerative colitis. A pancreatic lesion is one of the extraintestinal lesions in patients with IBD. Acute pancreatitis is the representative manifestation, and various causes of pancreatitis have been reported, including those involving adverse effects of drug therapies such as 5-aminosalicylic acid and thiopurines, gall stones, gastrointestinal lesions on the duodenum, iatrogenic harm accompanying endoscopic procedures such as balloon endoscopy, and autoimmunity. Of these potential causes, autoimmune pancreatitis (AIP) is a relatively newly recognized disease and is being increasingly diagnosed in IBD. AIP cases can be divided into type 1 cases involving lymphocytes and IgG4-positive plasma cells, and type 2 cases primarily involving neutrophils; the majority of AIP cases complicating IBD are type 2. The association between IBD and chronic pancreatitis, exocrine pancreatic insufficiency, pancreatic cancer, etc. has also been suggested; however, studies with high-quality level evidence are limited, and much remains unknown. In this review, we provide an overview of the etiology of pancreatic manifestation in patients with IBD.
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427
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Dalekos GN, Gatselis NK. Variant and Specific Forms of Autoimmune Cholestatic Liver Diseases. Arch Immunol Ther Exp (Warsz) 2019; 67:197-211. [PMID: 31165900 DOI: 10.1007/s00005-019-00550-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 05/31/2019] [Indexed: 12/12/2022]
Abstract
Primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) are the main autoimmune cholestatic liver diseases. IgG4-associated sclerosing cholangitis is another distinct immune-mediated cholestatic disorder of unknown aetiology that is frequently associated with autoimmune pancreatitis or other IgG4-related diseases. Although the majority of PBC and PSC patients have a typical presentation, there are common and uncommon important variants or specific subgroups that observed in everyday routine clinical practice. In this updated review, we summarize the published data giving also our own experience on the variants and specific groups of autoimmune cholestatic liver diseases. Actually, we give in detail the underlining difficulties and the rising dilemmas concerning the diagnosis and management of these special conditions in the clinical spectrum of autoimmune cholestatic liver diseases including the IgG4-associated sclerosing cholangitis highlighting also the uncertainties and the potential new eras of the research agenda.
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Affiliation(s)
- George N Dalekos
- Institute of Internal Medicine and Hepatology, Larissa, Greece.
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, 41110, Larissa, Greece.
| | - Nikolaos K Gatselis
- Institute of Internal Medicine and Hepatology, Larissa, Greece
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, 41110, Larissa, Greece
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428
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COUTO CA, TERRABUIO DRB, CANÇADO ELR, PORTA G, LEVY C, SILVA AEB, BITTENCOURT PL, CARVALHO FILHO RJD, CHAVES DM, MIURA IK, CODES L, FARIA LC, EVANGELISTA AS, FARIAS AQ, GONÇALVES LL, HARRIZ M, LOPES EPDA, LUZ GO, OLIVEIRA PMC, OLIVEIRA EMG, SCHIAVON JLN, SEVÁ-PEREIRA T. UPDATE OF THE BRAZILIAN SOCIETY OF HEPATOLOGY RECOMMENDATIONS FOR DIAGNOSIS AND MANAGEMENT OF AUTOIMMUNE DISEASES OF THE LIVER. ARQUIVOS DE GASTROENTEROLOGIA 2019; 56:232-241. [PMID: 31460591 DOI: 10.1590/s0004-2803.201900000-43] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 06/04/2019] [Indexed: 02/08/2023]
Abstract
ABSTRACT New data concerning the management of autoimmune liver diseases have emerged since the last single-topic meeting sponsored by the Brazilian Society of Hepatology to draw recommendations about the diagnosis and treatment of autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), overlap syndromes of AIH, PBC and PSC and specific complications and topics concerning AIH and cholestatic liver diseases. This manuscript updates those previous recommendations according to the best evidence available in the literature up to now. The same panel of experts that took part in the first consensus document reviewed all recommendations, which were subsequently scrutinized by all members of the Brazilian Society of Hepatology using a web-based approach. The new recommendations are presented herein.
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429
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Ursodeoxycholic Acid Therapy in Pediatric Primary Sclerosing Cholangitis: Predictors of Gamma Glutamyltransferase Normalization and Favorable Clinical Course. J Pediatr 2019; 209:92-96.e1. [PMID: 30878206 PMCID: PMC6535363 DOI: 10.1016/j.jpeds.2019.01.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/17/2019] [Accepted: 01/18/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate patient factors predictive of gamma glutamyltransferase (GGT) normalization following ursodeoxycholic acid (UDCA) therapy in children with primary sclerosing cholangitis. STUDY DESIGN We retrospectively reviewed patient records at 46 centers. We included patients with a baseline serum GGT level ≥50 IU/L at diagnosis of primary sclerosing cholangitis who initiated UDCA therapy within 1 month and continued therapy for at least 1 year. We defined "normalization" as a GGT level <50 IU/L without experiencing portal hypertensive or dominant stricture events, liver transplantation, or death during the first year. RESULTS We identified 263 patients, median age 12.1 years at diagnosis, treated with UDCA at a median dose of 15 mg/kg/d. Normalization occurred in 46%. Patients with normalization had a lower prevalence of Crohn's disease, lower total bilirubin level, lower aspartate aminotransferase to platelet ratio index, greater platelet count, and greater serum albumin level at diagnosis. The 5-year survival with native liver was 99% in those patients who achieved normalization vs 77% in those who did not. CONCLUSIONS Less than one-half of the patients treated with UDCA have a complete GGT normalization in the first year after diagnosis, but this subset of patients has a favorable 5-year outcome. Normalization is less likely in patients with a Crohn's disease phenotype or a laboratory profile suggestive of more advanced hepatobiliary fibrosis. Patients who do not achieve normalization could reasonably stop UDCA, as they are likely not receiving clinical benefit. Alternative treatments with improved efficacy are needed, particularly for patients with already-advanced disease.
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430
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Fung BM, Tabibian JH. Biliary endoscopy in the management of primary sclerosing cholangitis and its complications. LIVER RESEARCH 2019; 3:106-117. [PMID: 31341699 PMCID: PMC6656407 DOI: 10.1016/j.livres.2019.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic, idiopathic, cholestatic liver disease characterized by inflammation and fibrosis of the intrahepatic and/or extrahepatic bile ducts. It can affect individuals of all age groups and gender, has no established pharmacotherapy, and is associated with a variety of neoplastic (e.g. cholangiocarcinoma) and non-neoplastic (e.g. dominant strictures) hepatobiliary complications. Given these considerations, endoscopy plays a major role in the care of patients with PSC. In this review, we discuss and provide updates regarding endoscopic considerations in the management of hepatobiliary manifestations and complications of PSC. Where evidence is limited, we suggest pragmatic approaches based on currently available data and expert opinion.
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Affiliation(s)
- Brian M. Fung
- University of California Los Angeles-Olive View Internal Medicine Residency Program, Sylmar, CA, USA
| | - James H. Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-University of California Los Angeles Medical Center, Sylmar, CA, USA
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431
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Tanaka A. Emerging novel treatments for autoimmune liver diseases. Hepatol Res 2019; 49:489-499. [PMID: 30969002 DOI: 10.1111/hepr.13347] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/26/2019] [Accepted: 04/07/2019] [Indexed: 12/17/2022]
Abstract
The etiology of autoimmune liver diseases, such as autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC), still remains largely unknown and no therapeutic agents that are able to "cure" these diseases have been developed. Although corticosteroids for AIH and ursodeoxycholic acid for PBC have been shown to significantly improve liver transplantation (LT)-free survival and are recommended as first-line drugs, treatment strategies for patients who show incomplete response to these drugs have not yet been fully established. No drug is significantly associated with long LT-free survival in PSC patients. Nevertheless, with progress in genetics, immunology, and cellular biology, several new compounds or antibodies are expected to have an effect on autoimmune liver diseases and several drugs are under consideration for clinical use. Although most clinical trials have been carried out in the USA or Europe, some are, or will be, undertaken in Japan in the future. In this review, the current standard-of-care of autoimmune liver diseases will be summarized, together with emerging novel treatments relevant to clinical practice in Japan.
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432
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DPYD and Fluorouracil-Based Chemotherapy: Mini Review and Case Report. Pharmaceutics 2019; 11:pharmaceutics11050199. [PMID: 31052357 PMCID: PMC6572291 DOI: 10.3390/pharmaceutics11050199] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 12/13/2022] Open
Abstract
5-Fluorouracil remains a foundational component of chemotherapy for solid tumour malignancies. While considered a generally safe and effective chemotherapeutic, 5-fluorouracil has demonstrated severe adverse event rates of up to 30%. Understanding the pharmacokinetics of 5-fluorouracil can improve the precision medicine approaches to this therapy. A single enzyme, dihydropyrimidine dehydrogenase (DPD), mediates 80% of 5-fluorouracil elimination, through hepatic metabolism. Importantly, it has been known for over 30-years that adverse events during 5-fluorouracil therapy are linked to high systemic exposure, and to those patients who exhibit DPD deficiency. To date, pre-treatment screening for DPD deficiency in patients with planned 5-fluorouracil-based therapy is not a standard of care. Here we provide a focused review of 5-fluorouracil metabolism, and the efforts to improve predictive dosing through screening for DPD deficiency. We also outline the history of key discoveries relating to DPD deficiency and include relevant information on the potential benefit of therapeutic drug monitoring of 5-fluorouracil. Finally, we present a brief case report that highlights a limitation of pharmacogenetics, where we carried out therapeutic drug monitoring of 5-fluorouracil in an orthotopic liver transplant recipient. This case supports the development of robust multimodality precision medicine services, capable of accommodating complex clinical dilemmas.
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Saffioti F, Roccarina D, Vesterhus M, Hov JR, Rosenberg W, Pinzani M, Pereira SP, Boberg KM, Thorburn D. Cholangiocarcinoma is associated with a raised enhanced liver fibrosis score independent of primary sclerosing cholangitis. Eur J Clin Invest 2019; 49:e13088. [PMID: 30762236 DOI: 10.1111/eci.13088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cholangiocarcinoma (CCA) complicates primary sclerosing cholangitis (PSC) in 10%-20% of cases, but current tools for prediction of a CCA diagnosis are inadequate. Recently, we demonstrated the utility of the enhanced liver fibrosis (ELF) test to stratify prognosis in PSC. We observed that patients with PSC + CCA had significantly higher ELF score than those with PSC alone. In this study, we aimed to investigate further this association in a larger cohort of PSC patients with CCA compared with patients with PSC or CCA alone. MATERIALS AND METHODS Stored sera from patients with PSC (n = 119), CCA without known chronic liver disease (n = 36) and PSC + CCA (n = 32) were tested for ELF. ELF score, gender, age, age at disease diagnosis, inflammatory bowel disease, PSC duration and severity, and CCA features were compared amongst the three cohorts. Factors related to an elevated ELF score were investigated. RESULTS Enhanced liver fibrosis score was significantly higher in patients with CCA without underlying chronic liver disease and in patients with PSC + CCA compared to those with PSC alone (P < 0.001). In multivariate analysis, elevated ELF score was associated with the diagnosis of CCA independently of age and PSC status (P < 0.001). CONCLUSIONS Enhanced liver fibrosis score was elevated in patients with CCA irrespective of the presence of PSC, and independently of liver disease stage. Our results indicate that the association between high ELF score and CCA may be related to the tumour's desmoplastic nature, independent of background liver fibrosis, suggesting that ELF score could be used to risk stratify for CCA in PSC.
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Affiliation(s)
- Francesca Saffioti
- Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, University College London & Royal Free London NHS Foundation Trust, London, UK.,Department of Clinical and Experimental Medicine, Division of Clinical and Molecular Hepatology, University of Messina, Messina, Italy
| | - Davide Roccarina
- Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, University College London & Royal Free London NHS Foundation Trust, London, UK
| | - Mette Vesterhus
- Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Johannes R Hov
- Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway.,Section of Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - William Rosenberg
- Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, University College London & Royal Free London NHS Foundation Trust, London, UK
| | - Massimo Pinzani
- Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, University College London & Royal Free London NHS Foundation Trust, London, UK
| | - Stephen P Pereira
- Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, University College London & Royal Free London NHS Foundation Trust, London, UK
| | - Kirsten M Boberg
- Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway.,Section of Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Douglas Thorburn
- Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, University College London & Royal Free London NHS Foundation Trust, London, UK
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Abstract
Cholangiocytes, the epithelial cells lining the intrahepatic and extrahepatic bile ducts, are highly specialized cells residing in a complex anatomic niche where they participate in bile production and homeostasis. Cholangiocytes are damaged in a variety of human diseases termed cholangiopathies, often causing advanced liver failure. The regulation of cholangiocyte transport properties is increasingly understood, as is their anatomical and functional heterogeneity along the biliary tract. Furthermore, cholangiocytes are pivotal in liver regeneration, especially when hepatocyte regeneration is compromised. The role of cholangiocytes in innate and adaptive immune responses, a critical subject relevant to immune-mediated cholangiopathies, is also emerging. Finally, reactive ductular cells are present in many cholestatic and other liver diseases. In chronic disease states, this repair response contributes to liver inflammation, fibrosis and carcinogenesis and is a subject of intense investigation. This Review highlights advances in cholangiocyte research, especially their role in development and liver regeneration, their functional and biochemical heterogeneity, their activation and involvement in inflammation and fibrosis and their engagement with the immune system. We aim to focus further attention on cholangiocyte pathobiology and the search for new disease-modifying therapies targeting the cholangiopathies.
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435
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Sato K, Glaser S, Kennedy L, Liangpunsakul S, Meng F, Francis H, Alpini G. Preclinical insights into cholangiopathies: disease modeling and emerging therapeutic targets. Expert Opin Ther Targets 2019; 23:461-472. [PMID: 30990740 DOI: 10.1080/14728222.2019.1608950] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The common predominant clinical features of cholangiopathies such as primary sclerosing cholangitis (PSC), primary biliary cholangitis (PBC), and biliary atresia (BA) are biliary damage/senescence and liver fibrosis. Curative therapies are lacking, and liver transplantation is the only option. An understanding of the mechanisms and pathogenesis is needed to develop novel therapies. Previous studies have developed various disease-based research models and have identified candidate therapeutic targets. Areas covered: This review summarizes recent studies performed in preclinical models of cholangiopathies and the current understanding of the pathophysiology representing potential targets for novel therapies. A literature search was conducted in PubMed using the combination of the searched term 'cholangiopathies' with one or two keywords including 'model', 'cholangiocyte', 'animal', or 'fibrosis'. Papers published within five years were obtained. Expert opinion: Access to appropriate research models is a key challenge in cholangiopathy research; establishing more appropriate models for PBC is an important goal. Several preclinical studies have demonstrated promising results and have led to novel therapeutic approaches, especially for PSC. Further studies on the pathophysiology of PBC and BA are necessary to identify candidate targets. Innovative therapeutic approaches such as stem cell transplantation have been introduced, and those therapies could be applied to PSC, PBC, and BA.
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Affiliation(s)
- Keisaku Sato
- a Indiana Center for Liver Research, Division of Gastroenterology & Hepatology, Department of Medicine , Indiana University School of Medicine , Indianapolis , IN , USA.,b Richard L. Roudebush VA Medical Center , Indianapolis , IN , USA
| | - Shannon Glaser
- c Department of Medical Physiology , Texas A&M University Collage of Medicine , Temple , TX , USA
| | - Lindsey Kennedy
- a Indiana Center for Liver Research, Division of Gastroenterology & Hepatology, Department of Medicine , Indiana University School of Medicine , Indianapolis , IN , USA.,b Richard L. Roudebush VA Medical Center , Indianapolis , IN , USA
| | - Suthat Liangpunsakul
- a Indiana Center for Liver Research, Division of Gastroenterology & Hepatology, Department of Medicine , Indiana University School of Medicine , Indianapolis , IN , USA.,b Richard L. Roudebush VA Medical Center , Indianapolis , IN , USA
| | - Fanyin Meng
- a Indiana Center for Liver Research, Division of Gastroenterology & Hepatology, Department of Medicine , Indiana University School of Medicine , Indianapolis , IN , USA.,b Richard L. Roudebush VA Medical Center , Indianapolis , IN , USA
| | - Heather Francis
- a Indiana Center for Liver Research, Division of Gastroenterology & Hepatology, Department of Medicine , Indiana University School of Medicine , Indianapolis , IN , USA.,b Richard L. Roudebush VA Medical Center , Indianapolis , IN , USA
| | - Gianfranco Alpini
- a Indiana Center for Liver Research, Division of Gastroenterology & Hepatology, Department of Medicine , Indiana University School of Medicine , Indianapolis , IN , USA.,b Richard L. Roudebush VA Medical Center , Indianapolis , IN , USA
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436
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[Immune-mediated cholangiopathies : Diagnostic and therapeutic challenges]. Radiologe 2019; 59:348-356. [PMID: 30874827 DOI: 10.1007/s00117-019-0513-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Immune-mediated cholangiopathies comprise primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC) and IgG4-associated cholangitis (IAC). A common feature is the progressive destruction of bile ducts leading to cholestasis with fibrosis and cirrhosis of the liver over time. The diseases are mostly identified during routine laboratory testing. Clinical signs and symptoms such as pruritus, fatigue or jaundice are infrequent in the early stage. DIAGNOSIS The diagnostic work-up involves the patient's history, physical examination, serological tests, abdominal ultrasonography, magnetic resonance cholangiopancreatography (MRCP) and, where necessary, liver biopsy and genetic testing. THERAPY Ursodeoxycholic acid (UDCA) is an effective treatment of PBC. Second-line therapies in addition to UDCA for incomplete UDCA responders are obeticholic acid (OCA) and bezafibrate, whereby only OCA has received approval for this indication from American (Federal Drug Administration) and European (European Medicines Agency) authorities. In PSC, UDCA improves prognostic markers; dominant bile duct strictures are treated with endoscopic balloon dilatation. Despite therapy, liver transplantation is frequently necessary for PSC. The risk of developing cholangiocarcinoma, colon cancer, and gallbladder cancer is increased for patients with PSC. In contrast to PBC and PSC, IAC responds well to corticosteroids. Disease relapse, however, is common, making long-term treatment with low-dose prednisolone or azathioprine necessary.
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437
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Wannhoff A, Brune M, Knierim J, Weiss KH, Rupp C, Gotthardt DN. Longitudinal analysis of CA19-9 reveals individualised normal range and early changes before development of biliary tract cancer in patients with primary sclerosing cholangitis. Aliment Pharmacol Ther 2019; 49:769-778. [PMID: 30687954 DOI: 10.1111/apt.15146] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 07/23/2018] [Accepted: 12/27/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Primary sclerosing cholangitis is associated with an increased risk of biliary tract cancer. Carbohydrate antigen 19-9 (CA19-9) can be used to screen for these malignancies. AIM To perform a longitudinal analysis of CA19-9 in patients with primary sclerosing cholangitis. METHODS We conducted a retrospective analysis of CA19-9 values in patients who had primary sclerosing cholangitis, with and without biliary malignancy. We calculated the index of individuality and reference change value in patients who were cancer-free. Long-term analysis of CA19-9 in cancer-free patients was performed and we assessed the change of CA19-9 prior to diagnosis of cancer. RESULTS We obtained 1818 CA19-9 values from 247 patients, including 32 with malignancy. Median CA19-9 in cancer-free individuals was 15.6 U/mL. The index of individuality was 0.37 and the reference change value was 46.23%. In cancer-free patients, no significant change in CA19-9 was observed at 1, 2, 5, 7, 10, 15, and 20 years after initial diagnosis of primary sclerosing cholangitis. In patients with biliary tract cancer, CA19-9 was higher at 3 months prior to diagnosis (P < 0.05) than at 6 months before diagnosis and was also higher than at 3 months prior to last follow-up in cancer-free patients (P < 0.05). In 92.9% of patients with biliary cancer, we found an increase in CA19-9 of >46.23% in the year prior to cancer diagnosis. CONCLUSIONS CA19-9 in patients with primary sclerosing cholangitis is highly individual, and the reference change value should be preferred to reference intervals. In this study, CA19-9 remained stable in patients who were cancer-free but increased early in those who developed biliary tract cancer. Regular CA19-9 measurement might improve early detection of these malignancies.
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Affiliation(s)
- Andreas Wannhoff
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Maik Brune
- Department of Internal Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany
| | - Johannes Knierim
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Karl Heinz Weiss
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Rupp
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniel N Gotthardt
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany.,Mediteo GmbH, Heidelberg, Germany
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438
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Steenstraten IC, Sebib Korkmaz K, Trivedi PJ, Inderson A, van Hoek B, Rodriguez Girondo MDM, Maljaars PWJ. Systematic review with meta-analysis: risk factors for recurrent primary sclerosing cholangitis after liver transplantation. Aliment Pharmacol Ther 2019; 49:636-643. [PMID: 30740723 PMCID: PMC6593422 DOI: 10.1111/apt.15148] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 08/20/2019] [Accepted: 12/29/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND After liver transplantation primary sclerosing cholangitis (PSC), the condition returns in the transplanted liver in a subset of patients (recurrent primary sclerosing cholangitis, rPSC). AIM To define risk factors for rPSC. METHODS We searched Pubmed, Embase, Web of Science, and Cochrane library for articles published until March 2018. Studies addressing risk factors for developing rPSC were eligible for inclusion. A random effects meta-analysis was conducted using hazard ratios (HR) as effect measure. Study quality was evaluated with the Newcastle Ottawa scale. Statistical analysis was performed using Cochrane Review Manager. RESULTS The electronic database search yielded 449 results. Twenty-one retrospective cohort studies met the inclusion criteria for the review; 14 were included in the meta-analysis. The final cohort included 2159 patients (age range 31-49 years, 68.8% male), of whom 17.7% developed rPSC. Colectomy before liver transplantation, HR 0.65 (95% CI: 0.42-0.99), cholangiocarcinoma before liver transplantation, HR 2.42 (95% CI: 1.20-4.86), inflammatory bowel disease, HR 1.73 (95% CI: 1.17-2.54), donor age, HR 1.24 (95% CI 1.0-1.45) per ten years, MELD score, HR 1.05 (95% CI: 1.02-1.08) per point and acute cellular rejection, HR of 1.94 (95% CI: 1.32-2.83) were associated with the risk of rPSC. CONCLUSIONS Multiple risk factors for rPSC were identified. Colectomy before liver transplantation reduced the risk of rPSC.
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Affiliation(s)
- Iris C. Steenstraten
- Department of Gastroenterology and HepatologyLeiden University Medical CentreLeidenThe Netherlands
| | - Kerem Sebib Korkmaz
- Department of Gastroenterology and HepatologyLeiden University Medical CentreLeidenThe Netherlands
| | - Palak J. Trivedi
- National Institute for Health Research (NIHR) Birmingham Biomedical Research CentreBirminghamUK,University Hospitals BirminghamBirminghamUK,Institute of Immunology and ImmunotherapyUniversity of BirminghamBirminghamUK,Institute of Applied Health ResearchUniversity of BirminghamUK
| | - Akin Inderson
- Department of Gastroenterology and HepatologyLeiden University Medical CentreLeidenThe Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and HepatologyLeiden University Medical CentreLeidenThe Netherlands
| | | | - P. W. Jeroen Maljaars
- Department of Gastroenterology and HepatologyLeiden University Medical CentreLeidenThe Netherlands
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439
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Gerussi A, Invernizzi P. Better end points needed in primary sclerosing cholangitis trials. Nat Rev Gastroenterol Hepatol 2019; 16:143-144. [PMID: 30655632 DOI: 10.1038/s41575-019-0110-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Alessio Gerussi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
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440
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441
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Epigenetics of autoimmune liver diseases: current progress and future directions. JOURNAL OF BIO-X RESEARCH 2019. [DOI: 10.1097/jbr.0000000000000030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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442
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Hirschfield GM, Chazouillères O, Drenth JP, Thorburn D, Harrison SA, Landis CS, Mayo MJ, Muir AJ, Trotter JF, Leeming DJ, Karsdal MA, Jaros MJ, Ling L, Kim KH, Rossi SJ, Somaratne RM, DePaoli AM, Beuers U. Effect of NGM282, an FGF19 analogue, in primary sclerosing cholangitis: A multicenter, randomized, double-blind, placebo-controlled phase II trial. J Hepatol 2019; 70:483-493. [PMID: 30414864 DOI: 10.1016/j.jhep.2018.10.035] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/09/2018] [Accepted: 10/29/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Primary sclerosing cholangitis (PSC) is an inflammatory, cholestatic and progressively fibrotic liver disease devoid of effective medical intervention. NGM282, an engineered, non-tumorigenic FGF19 analogue, potently regulates CYP7A1-mediated bile acid homeostasis. We assessed the activity and safety of NGM282 in patients with PSC. METHODS In this double-blind, placebo-controlled phase II trial, 62 patients who had PSC confirmed by cholangiography or biopsy and an elevated alkaline phosphatase (ALP) >1.5 × the upper limit of normal were randomly assigned 1:1:1 to receive NGM282 1 mg, 3 mg or placebo once daily for 12 weeks. The primary outcome was the change in ALP from baseline to week 12. Secondary and exploratory outcomes included changes in serum biomarkers of bile acid metabolism and fibrosis. Efficacy analysis was by intention-to-treat. RESULTS At 12 weeks, there were no significant differences in the mean change from baseline in ALP between the NGM282 and placebo groups, and therefore, the primary endpoint was not met. However, NGM282 significantly reduced levels of 7alpha-hydroxy-4-cholesten-3-one (a marker of hepatic CYP7A1 activity, LS mean differences -6.2 ng/ml (95% CI -10.7 to -1.7; p = 0.008) and -9.4 ng/ml (-14.0 to -4.9; p <0.001) in the NGM282 1 mg and 3 mg groups, respectively, compared with placebo) and bile acids. Importantly, fibrosis biomarkers that predict transplant-free survival, including Enhanced Liver Fibrosis score and Pro-C3, were significantly improved following NGM282 treatment. Most adverse events were mild to moderate in severity, with gastrointestinal symptoms more frequent in the NGM282 treatment groups. CONCLUSIONS In patients with PSC, NGM282 potently inhibited bile acid synthesis and decreased fibrosis markers, without significantly affecting ALP levels. LAY SUMMARY We present for the first time, the clinical and laboratory effects of a first-in-class, engineered analogue of the endocrine hormone FGF19 in patients with primary sclerosing cholangitis (PSC). By incorporating non-invasive markers of fibrosis, beyond standard liver injury markers, we show that NGM282 impacted on fibrosis turnover and hepatic inflammation without changing alkaline phosphatase. Our findings demonstrate the complexities of using highly potent rational agents in PSC, and furthermore challenge the dogma about what the appropriate endpoints should be for trials in PSC.
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Affiliation(s)
- Gideon M Hirschfield
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, United Kingdom; University Hospitals Birmingham, Birmingham, United Kingdom; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom; Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada.
| | - Olivier Chazouillères
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, Hepatology and Gastroenterology Department, Saint-Antoine University Hospital, Assistance Publique-Hopitaux de Paris, and INSERM UMR S938, Sorbonne University, Paris, France
| | - Joost P Drenth
- Department of Gastroenterology and Hepatology, Radboud UMC, Nijmegen, the Netherlands
| | - Douglas Thorburn
- Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | | | - Charles S Landis
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, United States
| | - Marlyn J Mayo
- University Texas Southwestern Medical Center, Dallas, United States
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University, Durham, United States
| | - James F Trotter
- Texas Digestive Disease Consultants, Clinical Research, Southlake, United States
| | | | | | | | - Lei Ling
- NGM Biopharmaceuticals, South San Francisco, United States
| | - Kathline H Kim
- NGM Biopharmaceuticals, South San Francisco, United States
| | | | | | - Alex M DePaoli
- NGM Biopharmaceuticals, South San Francisco, United States
| | - Ulrich Beuers
- Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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443
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Affiliation(s)
- Peter Fickert
- Department of Gastroenterology and Hepatology, Medical University Graz, Graz, Austria.
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
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444
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Fung BM, Lindor KD, Tabibian JH. Cancer risk in primary sclerosing cholangitis: Epidemiology, prevention, and surveillance strategies. World J Gastroenterol 2019; 25:659-671. [PMID: 30783370 PMCID: PMC6378537 DOI: 10.3748/wjg.v25.i6.659] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/10/2019] [Accepted: 01/15/2019] [Indexed: 02/06/2023] Open
Abstract
Primary sclerosing cholangitis (PSC) is a rare cholestatic liver disease characterized by progressive fibroinflammatory destruction of the intra- and/or extrahepatic biliary ducts. While its features and disease course can be variable, most patients with PSC have concurrent inflammatory bowel disease and will eventually develop liver cirrhosis and end-stage liver disease, with liver transplantation representing the only potentially curative option. Importantly, PSC is associated with a significantly increased risk of malignancy compared to the general population, mainly cholangiocarcinoma, gallbladder carcinoma, hepatocellular carcinoma, and colorectal cancer, with nearly 50% of deaths in patients with PSC being due to cancer. Therefore, robust surveillance strategies are needed, though uncertainty remains regarding how to best do so. In this review, we discuss the epidemiology, prevention, and surveillance of cancers in patients with PSC. Where evidence is limited, we present pragmatic approaches based on currently available data and expert opinion.
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Affiliation(s)
- Brian M Fung
- UCLA-Olive View Internal Medicine Residency Program, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
| | - Keith D Lindor
- Office of the University Provost, Arizona State University, Phoenix, AZ 85004, United States
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
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445
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Muir AJ, Levy C, Janssen HLA, Montano-Loza AJ, Shiffman ML, Caldwell S, Luketic V, Ding D, Jia C, McColgan BJ, McHutchison JG, Mani Subramanian G, Myers RP, Manns M, Chapman R, Afdhal NH, Goodman Z, Eksteen B, Bowlus CL. Simtuzumab for Primary Sclerosing Cholangitis: Phase 2 Study Results With Insights on the Natural History of the Disease. Hepatology 2019; 69:684-698. [PMID: 30153359 DOI: 10.1002/hep.30237] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 08/16/2018] [Indexed: 02/06/2023]
Abstract
Lysyl oxidase like-2 (LOXL2) plays a central role in fibrogenesis and is elevated in the serum and liver of patients with primary sclerosing cholangitis (PSC). We evaluated the safety and efficacy of simtuzumab, a monoclonal antibody directed against LOXL2, in patients with PSC. Patients with compensated liver disease caused by PSC were randomized 1:1:1 to receive weekly subcutaneous injections of simtuzumab 75 mg, simtuzumab 125 mg, or placebo for 96 weeks. The primary efficacy endpoint was mean change in hepatic collagen content assessed by morphometry between baseline and week 96. Additional endpoints included change in Ishak fibrosis stage and the frequency of PSC-related clinical events. Overall, 234 patients were randomized and started treatment. At week 96, the mean change from baseline in hepatic collagen content was -0.5% for patients receiving simtuzumab 75 mg (P = 0.73 versus placebo), +0.5% for patients receiving simtuzumab 125 mg (P = 0.33 versus placebo), and 0.0 for patients receiving placebo. Compared with placebo, neither dose of simtuzumab led to significant reductions in Ishak fibrosis stage, progression to cirrhosis, or frequency of clinical events. Overall, 80 (34%) patients had fibrosis progression and 47 (20%) experienced PSC-related clinical events. In a multivariate model of baseline factors, PSC-related clinical events were more frequent in patients with advanced fibrosis (hazard ratio [HR], 2.03; 95% confidence interval [CI], 1.02-4.06; P = 0.045), higher alkaline phosphatase (HR per 10 U/L, 1.01; 95% CI, 1.00-1.02; P = 0.015), and higher enhanced liver fibrosis score (HR per unit, 1.26; 95% CI, 0.98-1.61; P = 0.073). Overall, rates of adverse events and laboratory abnormalities were similar between groups. Conclusion: Treatment with the LOXL2 inhibitor simtuzumab for 96 weeks did not provide clinical benefit in patients with PSC.
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Affiliation(s)
| | | | | | | | | | | | | | - Dora Ding
- Gilead Sciences, Inc, Foster City, CA
| | | | | | | | | | | | | | | | - Nezam H Afdhal
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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446
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Dhillon AK, Kummen M, Trøseid M, Åkra S, Liaskou E, Moum B, Vesterhus M, Karlsen TH, Seljeflot I, Hov JR. Circulating markers of gut barrier function associated with disease severity in primary sclerosing cholangitis. Liver Int 2019; 39:371-381. [PMID: 30269440 DOI: 10.1111/liv.13979] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/14/2018] [Accepted: 09/20/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS One important hypothesis in primary sclerosing cholangitis pathophysiology suggests that bacterial products from an inflamed leaky gut lead to biliary inflammation. We aimed to investigate whether circulating markers of bacterial translocation were associated with survival in a Norwegian primary sclerosing cholangitis cohort. METHODS Serum levels of zonulin, intestinal fatty acid binding protein, soluble CD14, lipopolysaccharide and lipopolysaccharide-binding protein were measured in 166 primary sclerosing cholangitis patients and 100 healthy controls. RESULTS Lipopolysaccharide-binding protein and soluble CD14 were elevated in primary sclerosing cholangitis compared with healthy controls (median 13 662 vs 12 339 ng/mL, P = 0.010 and 1657 vs 1196 ng/mL, P < 0.001, respectively). High soluble CD14 and lipopolysaccharide-binding protein (values >optimal cut-off using receiver operating characteristics) were associated with reduced liver transplantation-free survival (P < 0.001 and P = 0.005, respectively). The concentration of soluble CD14 was higher in patients with hepatobiliary cancer compared to other primary sclerosing cholangitis patients and healthy controls. Zonulin was lower in primary sclerosing cholangitis than controls, but when excluding primary sclerosing cholangitis patients with increased prothrombin time zonulin concentrations were similar in primary sclerosing cholangitis and healthy controls. Concomitant inflammatory bowel disease did not influence the results, while inflammatory bowel disease patients without primary sclerosing cholangitis (n = 40) had lower concentration of soluble CD14. In multivariable Cox regression, high soluble CD14 and high lipopolysaccharide-binding protein were associated with transplantation-free survival, independent from Mayo risk score (HR: 2.26 [95% CI: 1.15-4.43], P = 0.018 and HR: 2.00 [95% CI: 1.17-3.43], P = 0.011, respectively). CONCLUSIONS Primary sclerosing cholangitis patients show increased levels of circulating markers of bacterial translocation. High levels are associated with poor prognosis measured by transplantation-free survival, indicating that ongoing gut leakage could have clinical impact in primary sclerosing cholangitis.
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Affiliation(s)
- Amandeep K Dhillon
- Norwegian PSC Center, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Martin Kummen
- Norwegian PSC Center, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Marius Trøseid
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Sissel Åkra
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Ullevål, Norway
| | - Evaggelia Liaskou
- Centre for Liver Research, NIHR Birmingham Liver Biomedical Research Centre, Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, UK
| | - Bjørn Moum
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Division of Medicine, Oslo University Hospital Ullevål, Oslo, Norway
| | - Mette Vesterhus
- Norwegian PSC Center, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Tom H Karlsen
- Norwegian PSC Center, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Section of Gastroenterology, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Ingebjørg Seljeflot
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Ullevål, Norway
| | - Johannes R Hov
- Norwegian PSC Center, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Section of Gastroenterology, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway
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447
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Rompianesi G, Ravikumar R, Jose S, Allison M, Athale A, Creamer F, Gunson B, Manas D, Monaco A, Mirza D, Owen N, Roberts K, Sen G, Srinivasan P, Wigmore S, Fusai G, Fernando B, Burroughs A, Tsochatzis E. Incidence and outcome of colorectal cancer in liver transplant recipients: A national, multicentre analysis on 8115 patients. Liver Int 2019; 39:353-360. [PMID: 30129181 DOI: 10.1111/liv.13947] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 08/02/2018] [Accepted: 08/16/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS De novo malignancies after liver transplantation represent one of the leading causes of death in the long-term. It remains unclear whether liver transplant recipients have an increased risk of colorectal cancer and whether this negatively impacts on survival, particularly in those patients affected by primary sclerosing cholangitis and ulcerative colitis. METHODS In this national multicentre cohort retrospective study, the incidence of colorectal cancer in 8115 evaluable adult patients undergoing a liver transplantation between 1 January 1990 and 31 December 2010 was compared to the incidence in the general population through standardised incidence ratios. RESULTS Fifty-two (0.6%) cases of colorectal cancer were identified at a median of 5.6 years postliver transplantation, predominantly grade 2 (76.9%) and stage T3 (50%) at diagnosis. The incidence rate of colorectal cancer in the whole liver transplant population was similar to the general UK population (SIR: 0.92), but significantly higher (SIR: 7.0) in the group of patients affected by primary sclerosing cholangitis/ulcerative colitis. One-, five- and ten-year survival rates from colorectal cancer diagnosis were 71%, 48% and 31%, respectively, and the majority of colorectal cancer patients died of cancer-specific causes. CONCLUSIONS Liver transplantation alone is not associated with an increased risk of colorectal cancer development. The primary sclerosing cholangitis/ulcerative colitis liver transplant population showed a significantly higher risk of colorectal cancer development than the general population, with a high proportion of advanced stage at diagnosis and a reduced patient survival.
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Affiliation(s)
- Gianluca Rompianesi
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Reena Ravikumar
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Sophie Jose
- Research Department of Infection and Population Health, University College London, London, UK
| | - Michael Allison
- Cambridge Transplant Unit, Cambridge Biomedical Research Centre, Cambridge University Hospitals, Cambridge, UK
| | - Anuja Athale
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Felicity Creamer
- Department of HPB and Transplant Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Bridget Gunson
- The Liver Unit, University Hospitals Birmingham and NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Derek Manas
- Institute of Transplantation, Freeman Hospital, Newcastle, UK
| | - Andrea Monaco
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Darius Mirza
- The Liver Unit, University Hospitals Birmingham and NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Nicola Owen
- Cambridge Transplant Unit, Cambridge Biomedical Research Centre, Cambridge University Hospitals, Cambridge, UK
| | - Keith Roberts
- The Liver Unit, University Hospitals Birmingham and NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Gourab Sen
- Institute of Transplantation, Freeman Hospital, Newcastle, UK
| | | | - Stephen Wigmore
- Department of HPB and Transplant Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Giuseppe Fusai
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Bimbi Fernando
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Andrew Burroughs
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
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448
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von Seth E, Ouchterlony H, Dobra K, Hjerpe A, Arnelo U, Haas S, Bergquist A. Diagnostic performance of a stepwise cytological algorithm for biliary malignancy in primary sclerosing cholangitis. Liver Int 2019; 39:382-388. [PMID: 30507030 DOI: 10.1111/liv.14007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/31/2018] [Accepted: 11/03/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND AIMS Detection of early cholangiocarcinoma (CCA) in primary sclerosing cholangitis (PSC) is challenging. The aim of this study was to evaluate the diagnostic accuracy of a stepwise approach to biliary brush cytology with sequential use of fluorescence in-situ hybridization (FISH) for the detection of biliary malignancy in PSC. METHOD We retrospectively studied consecutive patients with PSC who underwent biliary brushings at Karolinska University Hospital between 2009 and 2015 (n = 208). Brush samples were categorized as benign, equivocal (atypical or suspicious) and malignant. Equivocal cases were further analysed with FISH. Samples with a malignant cytology or positive FISH were considered positive. The diagnosis was determined after 12 months of follow-up. RESULTS The diagnosis CCA was confirmed in 15 patients (7%), high-grade dysplasia in three patients, and low-grade dysplasia in five patients at follow-up. Using the diagnostic algorithm, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) for a diagnosis of CCA were 80% (95%CI 52%-96%), 96% (95%CI 92%-98%), 60% (95%CI 36%-81%) and 98% (95% CI 95%-100%). In patients with equivocal cytology (n = 61), the sensitivity for CCA diagnosis increased to 100% (95%CI 72%-100%) with a lower PPV of 58% (95%CI 34%-78%). The diagnostic accuracy for detection of CCA in all patients was 95% (95%CI 91%-97%). CONCLUSION Biliary brush cytology with sequential use of FISH in equivocal cases seems to be a highly predictive diagnostic test for CCA in PSC. These results support the use of FISH when cytology is equivocal for detection of biliary malignancy in PSC.
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Affiliation(s)
- Erik von Seth
- Division of Hepatology, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Unit of Gastroenterology and Rheumatology, Department of Medicine Huddinge (MedH), Karolinska Institutet, Stockholm, Sweden
| | - Helena Ouchterlony
- Unit of Gastroenterology and Rheumatology, Department of Medicine Huddinge (MedH), Karolinska Institutet, Stockholm, Sweden
| | - Katalin Dobra
- Division of Pathology, Department of Laboratory Medicine (LabMed), Karolinska Institutet, Stockholm, Sweden
| | - Anders Hjerpe
- Division of Pathology, Department of Laboratory Medicine (LabMed), Karolinska Institutet, Stockholm, Sweden
| | - Urban Arnelo
- Division of Hepatology, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Stephan Haas
- Division of Hepatology, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Unit of Gastroenterology and Rheumatology, Department of Medicine Huddinge (MedH), Karolinska Institutet, Stockholm, Sweden
| | - Annika Bergquist
- Division of Hepatology, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Unit of Gastroenterology and Rheumatology, Department of Medicine Huddinge (MedH), Karolinska Institutet, Stockholm, Sweden
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449
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Laborda TJ, Jensen MK, Kavan M, Deneau M. Treatment of primary sclerosing cholangitis in children. World J Hepatol 2019; 11:19-36. [PMID: 30705716 PMCID: PMC6354124 DOI: 10.4254/wjh.v11.i1.19] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/19/2018] [Accepted: 01/06/2019] [Indexed: 02/06/2023] Open
Abstract
Primary sclerosing cholangitis (PSC) is a rare disease of stricturing and destruction of the biliary tree with a complex genetic and environmental etiology. Most patients have co-occurring inflammatory bowel disease. Children generally present with uncomplicated disease, but undergo a variable progression to end-stage liver disease. Within ten years of diagnosis, 50% of children will develop clinical complications including 30% requiring liver transplantation. Cholangiocarcinoma is a rare but serious complication affecting 1% of children. Ursodeoxycholic acid and oral vancomycin therapy used widely in children as medical therapy, and may be effective in a subset of patients. Gamma glutamyltransferase is a potential surrogate endpoint for disease activity, with improved survival in patients who achieve a normal value. Endoscopic retrograde cholangiopancreatography is a necessary adjunct to medical therapy to evaluate mass lesions or dominant strictures for malignancy, and also to relieve biliary obstruction. Liver transplantation remains the only option for patients who progress to end-stage liver disease. We review special considerations for patients before and after transplant, and in patients with inflammatory bowel disease. There is presently no published treatment algorithm or guideline for the management of children with PSC. We review the evidence for drug efficacy, dosing, duration of therapy, and treatment targets in PSC, and provide a framework for endoscopic and medical management of this complex problem.
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Affiliation(s)
- Trevor J Laborda
- Department of Pediatrics, University of Utah, Salt Lake City, UT 84113, United States
| | - M Kyle Jensen
- Department of Pediatrics, University of Utah, Salt Lake City, UT 84113, United States
| | - Marianne Kavan
- Department of Pediatrics, University of Utah, Salt Lake City, UT 84113, United States
| | - Mark Deneau
- Department of Pediatrics, University of Utah, Salt Lake City, UT 84113, United States
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450
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Asrani SK, Devarbhavi H, Eaton J, Kamath PS. Burden of liver diseases in the world. J Hepatol 2019; 70:151-171. [PMID: 30266282 DOI: 10.1016/j.jhep.2018.09.014] [Citation(s) in RCA: 1877] [Impact Index Per Article: 375.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/10/2018] [Accepted: 09/17/2018] [Indexed: 02/06/2023]
Abstract
Liver disease accounts for approximately 2 million deaths per year worldwide, 1 million due to complications of cirrhosis and 1million due to viral hepatitis and hepatocellular carcinoma. Cirrhosis is currently the 11th most common cause of death globally and liver cancer is the 16th leading cause of death; combined, they account for 3.5% of all deaths worldwide. Cirrhosis is within the top 20 causes of disability-adjusted life years and years of life lost, accounting for 1.6% and 2.1% of the worldwide burden. About 2 billion people consume alcohol worldwide and upwards of 75 million are diagnosed with alcohol-use disorders and are at risk of alcohol-associated liver disease. Approximately 2 billion adults are obese or overweight and over 400 million have diabetes; both of which are risk factors for non-alcoholic fatty liver disease and hepatocellular carcinoma. The global prevalence of viral hepatitis remains high, while drug-induced liver injury continues to increase as a major cause of acute hepatitis. Liver transplantation is the second most common solid organ transplantation, yet less than 10% of global transplantation needs are met at current rates. Though these numbers are sobering, they highlight an important opportunity to improve public health given that most causes of liver diseases are preventable.
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Affiliation(s)
| | | | - John Eaton
- Mayo Clinic College of Medicine, Rochester, MN, USA
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