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Protich HE, Molleston JP, Bozic M, Pettit RS. Elexacaftor/Tezacaftor/Ivacaftor use in Pediatric Cystic Fibrosis Patients with Advanced Liver Disease. J Cyst Fibros 2024:S1569-1993(24)00040-7. [PMID: 38580564 DOI: 10.1016/j.jcf.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 02/29/2024] [Accepted: 03/19/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy extends the life expectancy of people with cystic fibrosis (PwCF). However, CFTR modulators have not been well studied in patients with cystic fibrosis liver disease (CFLD), specifically those with advanced liver disease with portal hypertension. The purpose of this report is to describe the use of elexacaftor/tezacaftor/ivacaftor (ETI) in pediatric CF patients with advanced CFLD. METHODS This retrospective case series included PwCF < 18 years old with baseline advanced CFLD initiated on ETI. RESULTS Eleven PwCF and advanced CFLD were treated with ETI; six started a reduced dose regimen. No patient required treatment interruption and four patients received dose changes related to increase in transaminase and/or bilirubin elevations. Mean (SD) change in ppFEV1 from prior to ETI to highest value during therapy was 14.27 % (4.25) (p = 0.007). When evaluating the group as whole, AST decreased from baseline to last reported -15.18 (23.23) units/L (p = 0.054) and ALT slightly increased 0.73 (39.13) units/L (p = 0.96). Bilirubin increased minimally overall for patients with mean change from baseline of 0.83 (1.33) mg/dL [range -0.5-3] (p = 0.17). A model for time on ETI showed a significant decrease in AST over time of 0.955 per month of ETI but no other liver biochemistries were significant. No patient experienced decompensation of CFLD. CONCLUSION ETI therapy in pediatric CF patients with advanced CFLD can be beneficial in improving pulmonary and nutritional outcomes without negative impact on liver biochemistries or hepatic outcomes. Close monitoring is recommended to ensure safety and tolerability.
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Affiliation(s)
- Hannah E Protich
- Department of Pharmacy, Riley Hospital for Children at IU Health, 705 Riley Hospital Drive, Simon Family Tower W6111, Indianapolis, IN, USA.
| | - Jean P Molleston
- Department of Pediatric Gastroenterology, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 4210, Indianapolis, Indiana, USA
| | - Molly Bozic
- Department of Pediatric Gastroenterology, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 4210, Indianapolis, Indiana, USA
| | - Rebecca S Pettit
- Department of Pharmacy, Riley Hospital for Children at IU Health, 705 Riley Hospital Drive, Simon Family Tower W6111, Indianapolis, IN, USA
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2
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Valamparampil JJ, Gupte GL. Cystic fibrosis associated liver disease in children. World J Hepatol 2021; 13:1727-1742. [PMID: 34904041 PMCID: PMC8637674 DOI: 10.4254/wjh.v13.i11.1727] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/19/2021] [Accepted: 09/17/2021] [Indexed: 02/06/2023] Open
Abstract
Cystic fibrosis (CF) is an autosomal recessive disorder caused by mutations in the CF transmembrane conductance regulator gene. CF liver disease develops in 5%-10% of patients with CF and is the third leading cause of death among patients with CF after pulmonary disease or lung transplant complications. We review the pathogenesis, clinical presentations, complications, diagnostic evaluation, effect of medical therapies especially CF transmembrane conductance regulator modulators and liver transplantation in CF associated liver disease.
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Affiliation(s)
| | - Girish L Gupte
- Liver Unit, Birmingham Children’s Hospital, Birmingham B4 6NH, United Kingdom
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Hercun J, Alvarez F, Vincent C, Bilodeau M. Cystic fibrosis liver disease: A condition in need of structured transition and continuity of care. CANADIAN LIVER JOURNAL 2019; 2:71-83. [PMID: 35990223 PMCID: PMC9202747 DOI: 10.3138/canlivj-2018-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 09/10/2018] [Indexed: 08/05/2023]
Abstract
Liver disease affects one-third of patients with cystic fibrosis (CF) and it is one of the major causes of morbidity and mortality in these patients. Historically considered a disease of childhood, its impact is now seen more often in adulthood. The heterogeneous pattern of CF liver disease and its rapid progression to cirrhosis remain a diagnostic challenge and new questions pertaining to the nature of liver involvement have recently been raised. Non-invasive measures to stratify the severity of liver involvement are increasingly used to predict clinical outcomes. A single treatment, ursodeoxycholic acid, has been used to slow progression of liver disease while recent advances in the field of CF treatments are promising. Management of portal hypertension remains challenging but outcomes after liver transplantation are encouraging. While many questions remain unanswered, a growing number of CF patients reach adulthood and will require care for CF liver disease.
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Affiliation(s)
- Julian Hercun
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
| | - Fernando Alvarez
- Gastroenterology, Hepatology and Nutrition Division, CHU Sainte-Justine, Montréal, Québec
| | - Catherine Vincent
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
| | - Marc Bilodeau
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
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Regard L, Lafoeste H, Martin C, Chassagnon G, Burgel PR. [Ageing with cystic fibrosis: Classical and emerging comorbidities in adults with cystic fibrosis]. REVUE DE PNEUMOLOGIE CLINIQUE 2018; 74:279-291. [PMID: 30316653 DOI: 10.1016/j.pneumo.2018.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Cystic fibrosis (CF) is a genetic disease with pulmonary involvement being predominant and often leading to respiratory failure and premature death. Non-pulmonary complications related to CF transmembrane conductance regulator (CFTR) defect are numerous and account for significant morbidity (exocrine pancreatic insufficiency, diabetes, CF-related liver disease, chronic sinusitis, osteoporosis). Improvement in patients' care led to a continuous increase in life expectancy, with a subsequent increase in the number of adult CF patients worldwide. Increased life expectancy comes with increased prevalence of CF-related comorbidities, but also with new emerging complications directly related to ageing (chronic kidney disease, cardiovascular risk factors, cancers). CFTR modulators might also contribute to modify the face of CF epidemiology and prognosis. Ageing with CF has become a challenge for CF patients and caregivers. This review summarizes classic and emerging comorbidities in the context of current growth and ageing of the CF population. It also addresses potential roles of CFTR modulators.
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Affiliation(s)
- L Regard
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - H Lafoeste
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - C Martin
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - G Chassagnon
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service d'imagerie médicale, hôpital Cochin, AP-HP, 75014 Paris, France
| | - P-R Burgel
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France.
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5
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Leung DH, Narkewicz MR. Cystic Fibrosis-related cirrhosis. J Cyst Fibros 2017; 16 Suppl 2:S50-S61. [DOI: 10.1016/j.jcf.2017.07.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/01/2017] [Accepted: 07/03/2017] [Indexed: 12/14/2022]
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Abstract
BACKGROUND Abnormal biliary secretion leads to the thickening of bile and the formation of plugs within the bile ducts; the consequent obstruction and abnormal bile flow ultimately results in the development of cystic fibrosis-related liver disease. This condition peaks in adolescence with up to 20% of adolescents with cystic fibrosis developing chronic liver disease. Early changes in the liver may ultimately result in end-stage liver disease with people needing transplantation. One therapeutic option currently used is ursodeoxycholic acid. This is an update of a previous review. OBJECTIVES To analyse evidence that ursodeoxycholic acid improves indices of liver function, reduces the risk of developing chronic liver disease and improves outcomes in general in cystic fibrosis. SEARCH METHODS We searched the Cochrane CF and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. We also contacted drug companies and searched online trial registries.Date of the most recent search of the Group's trials register: 09 April 2017. SELECTION CRITERIA Randomised controlled trials of the use of ursodeoxycholic acid for at least three months compared with placebo or no additional treatment in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial eligibility and quality. The authors used GRADE to assess the quality of the evidence. MAIN RESULTS Twelve trials have been identified, of which four trials involving 137 participants were included; data were only available from three of the trials (118 participants) since one cross-over trial did not report appropriate data. The dose of ursodeoxycholic acid ranged from 10 to 20 mg/kg/day for up to 12 months. The complex design used in two trials meant that data could only be analysed for subsets of participants. There was no significant difference in weight change, mean difference -0.90 kg (95% confidence interval -1.94 to 0.14) based on 30 participants from two trials. Improvement in biliary excretion was reported in only one trial and no significant change after treatment was shown. There were no data available for analysis for long-term outcomes such as death or need for liver transplantation. AUTHORS' CONCLUSIONS There are few trials assessing the effectiveness of ursodeoxycholic acid. The quality of the evidence identified ranged from low to very low. There is currently insufficient evidence to justify its routine use in cystic fibrosis.
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Affiliation(s)
- Katharine Cheng
- c/o Cochrane CFGD Group, Department of Women's and Children's Health, University of Liverpool, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, UK, L12 2AP
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Evans WR, Nicoli ER, Wang RY, Movsesyan N, Platt FM. Case Report: Ursodeoxycholic acid treatment in Niemann-Pick disease type C; clinical experience in four cases. Wellcome Open Res 2017; 2:75. [PMID: 29119141 PMCID: PMC5649119 DOI: 10.12688/wellcomeopenres.11854.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2017] [Indexed: 01/04/2023] Open
Abstract
In this case series, we demonstrate that Ursodeoxycholic acid (UDCA) improves liver dysfunction in Niemann-Pick type C (NPC) and may restore a suppressed cytochrome p450 system. NPC disease is a progressive neurodegenerative lysosomal storage disease caused by mutations in either the NPC1 or NPC2 genes. Liver disease is a common feature presenting either acutely as cholestatic jaundice in the neonatal period, or in later life as elevated liver enzymes indicative of liver dysfunction. Recently, an imbalance in bile acid synthesis in a mouse model of NPC disease was linked to suppression of the P450 detoxification system and was corrected by UDCA treatment. UDCA (3α, 7β-dihydroxy-5β-cholanic acid), a hydrophilic bile acid, is used to treat various cholestatic disorders. In this report we summarise the findings from four independent cases of NPC, three with abnormal liver enzyme levels at baseline, that were subsequently treated with UDCA. The patients differed in age and clinical features, they all tolerated the drug well, and in those with abnormal liver function, there were significant improvements in their liver enzyme parameters.
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Affiliation(s)
| | | | - Raymond Y. Wang
- Division of Metabolic Disorders, CHOC Children’s, Orange, CA, 92868, USA
- Department of Pediatrics, University of California-Irvine, Irvine, CA, 92617, USA
| | - Nina Movsesyan
- Division of Metabolic Disorders, CHOC Children’s, Orange, CA, 92868, USA
| | - Frances M. Platt
- Department of Pharmacology, University of Oxford, Oxford, OX1 3QT, UK
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Fiorotto R, Strazzabosco M. Cystic Fibrosis-Related Liver Diseases: New Paradigm for Treatment Based on Pathophysiology. Clin Liver Dis (Hoboken) 2016; 8:113-116. [PMID: 31041076 PMCID: PMC6490209 DOI: 10.1002/cld.583] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 08/05/2016] [Indexed: 02/04/2023] Open
Affiliation(s)
- Romina Fiorotto
- Section of Digestive Diseases, Liver CenterYale UniversityNew HavenCT,International Center for Digestive HealthUniversity of Milan‐BicoccaMilanItaly
| | - Mario Strazzabosco
- Section of Digestive Diseases, Liver CenterYale UniversityNew HavenCT,International Center for Digestive HealthUniversity of Milan‐BicoccaMilanItaly,Section of Digestive Diseases, Department of Medicine and SurgeryUniversity of Milan‐BicoccaMilanItaly
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9
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Ursodeoxycholic acid treatment is associated with improvement of liver stiffness in cystic fibrosis patients. J Cyst Fibros 2016; 15:834-838. [DOI: 10.1016/j.jcf.2016.07.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 07/20/2016] [Accepted: 07/20/2016] [Indexed: 12/11/2022]
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10
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Narkewicz MR. Cystic Fibrosis Liver Disease and Ursodeoxycholic Acid: One Small Step Forward, Miles to Go. J Pediatr 2016; 177:17-18. [PMID: 27423176 DOI: 10.1016/j.jpeds.2016.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 06/07/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Michael R Narkewicz
- Department of Pediatrics Section of Pediatric Gastroenterology, Hepatology and Nutrition Children's Hospital Colorado Digestive Health Institute University of Colorado School of Medicine Aurora, Colorado.
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Sathe MN, Freeman AJ. Gastrointestinal, Pancreatic, and Hepatobiliary Manifestations of Cystic Fibrosis. Pediatr Clin North Am 2016; 63:679-98. [PMID: 27469182 DOI: 10.1016/j.pcl.2016.04.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pulmonary disease is the primary cause of morbidity and mortality in people with cystic fibrosis (CF), but significant involvement within gastrointestinal, pancreatic, and hepatobiliary systems occurs as well. As in the airways, defects in CFTR alter epithelial surface fluid, mucus viscosity, and pH, increasing risk of stasis through the various hollow epithelial-lined structures of the gastrointestinal tract. This exerts secondary influences that are responsible for most gastrointestinal, pancreatic, and hepatobiliary manifestations of CF. Understanding these gastrointestinal morbidities of CF is essential in understanding and treating CF as a multisystem disease process and improving overall patient care.
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Affiliation(s)
- Meghana Nitin Sathe
- Division of Pediatric Gastroenterology and Nutrition, Children's Health, University of Texas Southwestern, F4.06, 1935 Medical District Drive, Dallas, TX 75235, USA
| | - Alvin Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University, 2015 Uppergate Drive, Northeast, Atlanta, GA 30322, USA.
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