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Wang H, Vannilam A, Hafberg ET, Gillis LA, Kassardjian A, Naini BV, Prasad V, Kelly DR, Mroczek-Musulman EC, Knox K, Correa H, Liang J. Clinical and Histopathologic Characteristics of Acute Severe Hepatitis Associated With Human Herpesvirus 6 Infection. Am J Surg Pathol 2024; 48:1117-1130. [PMID: 38907627 DOI: 10.1097/pas.0000000000002266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2024]
Abstract
Acute severe hepatitis associated with active human herpesvirus 6 (HHV-6) infection is a rare life-threatening condition with unclear clinical course and histopathology. In this study, we retrospectively analyzed 5 patients with indeterminate acute severe hepatitis found to have active hepatic HHV-6 infection during care. All patients were previously healthy children presenting with a nonspecific prodrome. Four developed acute liver failure (ALF) and 3 received liver transplantation. The explanted livers and biopsies demonstrated a centrilobular pattern of necroinflammation characterized by moderate to marked central perivenulitis and confluent centrilobular to panlobular necrosis in 4 cases, accompanied by marked hepatocellular swelling and milder portal inflammation in 3. Central perivenulitis was more prominent in comparison to a control of group of ALF without HHV-6 ( P =0.01). When compared with the children with acute severe hepatitis associated with adenovirus encountered in the recent outbreak, both central perivenulitis and centrilobular necrosis were significant predictors for association with HHV-6 ( P <0.01). Liver immunohistochemistry detected HHV-6 structural protein in biliary epithelium in all cases and a predominance of CD8 + T cells in the perivenular inflammatory infiltrate. Among the 4 patients with ALF, one received early anti-HHV-6 therapy and had transplant-free survival, while the other 3 received either general prophylactic antiviral treatment only (n=2) or late anti-HHV-6 therapy (n=1) and needed liver transplantation. Our findings were similar to those in previously reported cases. In summary, acute severe hepatitis associated with HHV-6 tends to affect children, progress to ALF, and exhibit characteristic centrilobular necroinflammation which likely represents an immune-mediated process.
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Affiliation(s)
- Huiying Wang
- Department of Pathology, Microbiology and Immunology
| | - Annette Vannilam
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN
| | - Einar T Hafberg
- Landspitali University Hospital, Reykjavík, Capital Region, Iceland
| | - Lynette A Gillis
- Division of Gastroenterology, Department of Pediatrics, University of Louisville, Louisville, KY
| | | | - Bita V Naini
- Department of Pathology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Vinay Prasad
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH
| | - David R Kelly
- Department of Pathology and Laboratory Medicine, Children's of Alabama, Birmingham, AL
| | | | | | - Hernan Correa
- Department of Pathology, Microbiology and Immunology
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Uchida H, Hong SK, Okumura S, Cherukuru R, Sanada Y, Yamada Y, Reddy MS, Matsuura T, Hara T, Chen CL, Yi NJ, Ikegami T, Kasahara M. Current Status and Outcomes of Living Donor Liver Transplantation for Pediatric Acute Liver Failure: Results From a Multicenter Retrospective Study Over Two Decades. Pediatr Transplant 2024; 28:e14838. [PMID: 39158111 DOI: 10.1111/petr.14838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 07/03/2024] [Accepted: 07/26/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Although the outcomes of living donor liver transplantation (LDLT) for pediatric acute liver failure (PALF) have improved, patient survival remains lower than in patients with chronic liver disease. We investigated whether the poor outcomes of LDLT for PALF persisted in the contemporary transplant era. METHODS We analyzed 193 patients who underwent LDLT between December 2000 and December 2020. The outcomes of patients managed in 2000-2010 (era 1) and 2011-2020 (era 2) were compared. RESULTS The median age at the time of LDLT was 1.2 years both eras. An unknown etiology was the major cause in both groups. Patients in era 1 were more likely to have surgical complications, including hepatic artery and biliary complications (p = 0.001 and p = 0.013, respectively). The era had no impact on the infection rate after LDLT (cytomegalovirus, Epstein-Barr virus, and sepsis). The mortality rates of patients and grafts in era one were significantly higher (p = 0.03 and p = 0.047, respectively). The 1- and 5-year survival rates were 76.4% and 70.9%, respectively, in era 1, while they were 88.3% and 81.9% in era 2 (p = 0.042). Rejection was the most common cause of graft loss in both groups. In the multivariate analysis, sepsis during the 30 days after LDLT was independently associated with graft loss (p = 0.002). CONCLUSIONS The survival of patients with PALF has improved in the contemporary transplant era. The early detection and proper management of rejection in patients, while being cautious of sepsis, should be recommended to improve outcomes further.
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Affiliation(s)
- Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Shinya Okumura
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ramkiran Cherukuru
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
| | - Yukihiro Sanada
- Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Mettu Srinivas Reddy
- Institute of Liver Disease and Transplantation, Gleneagles Global Health City, Chennai, India
| | - Toshiharu Matsuura
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanobu Hara
- Department of Surgery, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan
| | - Chao-Long Chen
- Department of Surgery, Liver Transplantation Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Toru Ikegami
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Oue H, Hiejima E, Okajima H, Okamoto T, Ogawa E, Uebayashi EY, Hatano E, Suga T, Hanami Y, Ashina K, Kai S, Sogo T, Inui A, Matsubara T, Sakai K, Yanagita M, Haga H, Minamiguchi S, Yamada Y, Nihira H, Izawa K, Yasumi T, Takita J. Efficacy of steroid therapy for improving native liver survival after pediatric acute liver failure with immune activation. Hepatol Res 2024. [PMID: 39167365 DOI: 10.1111/hepr.14107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 07/27/2024] [Accepted: 08/06/2024] [Indexed: 08/23/2024]
Abstract
AIM Recent evidence suggests that acute liver failure (ALF) in some patients may reflect a dysregulated immune response, and that corticosteroids improve survival of the native liver in ALF patients with high serum alanine aminotransferase levels, which are an indication of liver inflammation. However, it is unclear whether steroids are effective for pediatric acute liver failure (PALF). The aim of this retrospective case-control study is to examine whether steroid therapy for PALF accompanied by immune activation improves the survival of native liver and to identify factors that predict responses to steroid treatment. METHODS Of 38 patients with PALF treated at Kyoto University Hospital from February 2006 to August 2022, 19 receiving steroids who met the specific criteria for identifying the pathophysiology of immune activity in the liver (the "Steroid group"), and seven steroid-free patients who also met the criteria ("Nonsteroid group") were enrolled. Patients in the "Steroid group" were categorized as "responders" or "nonresponders" according to treatment outcome. Clinical and histological data were analyzed. RESULTS Survival of the native liver in the Steroid group was significantly higher than that in the Nonsteroid group (68% vs. 0%, respectively; p = 0.0052). Nonresponders were significantly younger, with higher Model for End-stage Liver Disease and pediatric end-stage liver disease scores, higher prothrombin time - international normalized ratio, and higher serum ferritin levels than responders. Massive hepatic necrosis was more common in nonresponders. CONCLUSION Steroid therapy is effective for PALF patients with liver inflammation; however, liver transplantation should be prioritized for young children with ALF accompanied by severe coagulopathy or massive hepatic necrosis.
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Affiliation(s)
- Hiroshi Oue
- Department of Pediatrics, Kyoto University, Kyoto, Japan
| | - Eitaro Hiejima
- Department of Pediatrics, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Department of Surgery (HBP and Transplantation/Pediatric Surgery), Kyoto University, Kyoto, Japan
- Department of Pediatric Surgery, Kanazawa Medical University Hospital, Kanazawa, Japan
| | - Tatsuya Okamoto
- Department of Surgery (HBP and Transplantation/Pediatric Surgery), Kyoto University, Kyoto, Japan
| | - Eri Ogawa
- Department of Surgery (HBP and Transplantation/Pediatric Surgery), Kyoto University, Kyoto, Japan
| | - Elena Yukie Uebayashi
- Department of Surgery (HBP and Transplantation/Pediatric Surgery), Kyoto University, Kyoto, Japan
| | - Etsuro Hatano
- Department of Surgery (HBP and Transplantation/Pediatric Surgery), Kyoto University, Kyoto, Japan
| | - Takenori Suga
- Department of Pediatrics, Kyoto University, Kyoto, Japan
| | - Yotaro Hanami
- Department of Pediatrics, Kyoto University, Kyoto, Japan
| | | | - Shinichi Kai
- Department of Anesthesia, Kyoto University, Kyoto, Japan
| | - Tsuyoshi Sogo
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama, Japan
| | - Ayano Inui
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama, Japan
| | | | - Kaoru Sakai
- Department of Nephrology, Kyoto University, Kyoto, Japan
| | | | - Hironori Haga
- Department of Diagnostic Pathology, Kyoto University, Kyoto, Japan
| | | | - Yosuke Yamada
- Department of Diagnostic Pathology, Kyoto University, Kyoto, Japan
| | - Hiroshi Nihira
- Department of Pediatrics, Kyoto University, Kyoto, Japan
| | - Kazushi Izawa
- Department of Pediatrics, Kyoto University, Kyoto, Japan
| | | | - Junko Takita
- Department of Pediatrics, Kyoto University, Kyoto, Japan
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Guo R, Yu Y, Xu C, Ma M, Hou C, Dong X, Wu J, Ouyang C, Ling J, Huang T. Protective effects of curcumin on corneal endothelial cell PANoptosis and monocyte adhesion induced by tumor necrosis factor-alpha and interferon-gamma in rats. Exp Eye Res 2024; 245:109952. [PMID: 38838973 DOI: 10.1016/j.exer.2024.109952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/18/2024] [Accepted: 06/02/2024] [Indexed: 06/07/2024]
Abstract
Decrease of human corneal endothelial cell (CEC) density leads to corneal edema, progressive corneal opacity, and reduced visual acuity. A reduction in CEC density may be related to elevated levels of inflammatory cytokines, such as tumor necrosis factor (TNF)-α and interferon (INF)-γ. PANoptosis, characterized by the activation of apoptosis, necroptosis, and pyroptosis, could be a factor in the loss of CECs driven by TNF-α and INF-γ. Cytokines also stimulate monocytes adhesion to endothelium. It has been shown in previous research that curcumin plays protective roles against numerous corneal inflammatory diseases. However, it is not determined whether curcumin acts as an anti-PANoptotic agent or if it mitigates monocyte adhesion to CECs. Therefore, this research aimed to explor the potential therapeutic effects of curcumin and its underlying mechanisms in the loss of CECs. CEC injury models were established, and curcumin was injected subconjunctivally. Clinical evaluation of the corneas was conducted using a scoring system and anterior segment photography. Corneal observation was performed with hematoxylin and eosin staining and immunostaining of zona occludens-1(ZO-1). Apoptotic cells within the corneal endothelium were observed using TUNEL staining. The detection of primary proteins expression was accomplished through Western blot analysis. Interleukin (IL)-1β and macrophage chemotactic protein 1 (MCP-1) levels were determined via ELISA, while the expression of cleaved caspase-3, gasdermin-D (GSDMD), phosphor-mixed lineage kinase domain-like protein (p-MLKL) and intercellular cell adhesion molecule-1 were confirmed by immunofluorescence. Myeloperoxidase (MPO) activity was measured in aqueous humors. Curcumin treatment attenuated the loss of CECs and corneal edema caused by TNF-α and IFN-γ. Besides, it decreased the count of TUNEL-positive cells, and inhibited the upregulation of cleaved caspase-3, cleaved caspase-6, cleaved caspase-7, and cleaved poly (ADP-ribose) polymerase. Moreover, both the expression and phosphorylation of MLKL and receptor-interacting protein 3 were decreased in curcumin-treated rats. Furthermore, curcumin also lowered the expression of cleaved caspase-1, diminished the levels of IL1β and MCP-1, and inhibited the activity of MPO. Besides, the expression of intercellular cell adhesion molecule-1, vascular cell adhesion molecule-1, as well as the number of CD11b-positive cells adhered to the CECs decreased for the administration of curcumin.
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Affiliation(s)
- Ruilin Guo
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Yi Yu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Chenjia Xu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Minglu Ma
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Chao Hou
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Xiaojuan Dong
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Jing Wu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Chen Ouyang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Jie Ling
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China
| | - Ting Huang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, China.
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Hegarty R, Thompson RJ. Genetic aetiologies of acute liver failure. J Inherit Metab Dis 2024; 47:582-597. [PMID: 38499319 DOI: 10.1002/jimd.12733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 03/20/2024]
Abstract
Acute liver failure (ALF) is a rare, rapidly evolving, clinical syndrome with devastating consequences where definitive treatment is by emergency liver transplantation. Establishing a diagnosis can be challenging and, historically, the cause of ALF was unidentified in up to half of children. However, recent technological and clinical advances in genomic medicine have led to an increasing proportion being diagnosed with monogenic aetiologies of ALF. The conditions encountered include a diverse group of inherited metabolic disorders each with prognostic and treatment implications. Often these disorders are clinically indistinguishable and may even mimic disorders of immune regulation or red cell disorders. Rapid genomic sequencing for children with ALF is, therefore, a key component in the diagnostic work up today. This review focuses on the monogenic aetiologies of ALF.
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Affiliation(s)
- Robert Hegarty
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
- Institute of Liver Studies, King's College London, London, UK
| | - Richard J Thompson
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
- Institute of Liver Studies, King's College London, London, UK
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Lülecioğlu AA, Yazıcı YY, Baran A, Warasnhe K, Beyaz Ş, Aytekin C, Özçay F, Aydemir Y, Barış Z, Belkaya S. Whole-exome sequencing for genetic diagnosis of idiopathic liver injury in children. J Cell Mol Med 2024; 28:e18485. [PMID: 38864694 PMCID: PMC11167704 DOI: 10.1111/jcmm.18485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/08/2024] [Accepted: 05/28/2024] [Indexed: 06/13/2024] Open
Abstract
Genome-wide approaches, such as whole-exome sequencing (WES), are widely used to decipher the genetic mechanisms underlying inter-individual variability in disease susceptibility. We aimed to dissect inborn monogenic determinants of idiopathic liver injury in otherwise healthy children. We thus performed WES for 20 patients presented with paediatric-onset recurrent elevated transaminases (rELT) or acute liver failure (ALF) of unknown aetiology. A stringent variant screening was undertaken on a manually-curated panel of 380 genes predisposing to inherited human diseases with hepatobiliary involvement in the OMIM database. We identified rare nonsynonymous variants in nine genes in six patients (five rELT and one ALF). We next performed a case-level evaluation to assess the causal concordance between the gene mutated and clinical symptoms of the affected patient. A genetic diagnosis was confirmed in four rELT patients (40%), among whom two carried novel mutations in ACOX2 or PYGL, and two had previously-reported morbid variants in ABCB4 or PHKA2. We also detected rare variants with uncertain clinical significance in CDAN1, JAG1, PCK2, SLC27A5 or VPS33B in rELT or ALF patients. In conclusion, implementation of WES improves diagnostic yield and enables precision management in paediatric cases of liver injury with unknown aetiology, in particular recurrent hypertransaminasemia.
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Affiliation(s)
- Aysima Atılgan Lülecioğlu
- Department of Molecular Biology and Genetics, Faculty of Scienceİhsan Doğramacı Bilkent UniversityAnkaraTurkey
| | - Yılmaz Yücehan Yazıcı
- Department of Molecular Biology and Genetics, Faculty of Scienceİhsan Doğramacı Bilkent UniversityAnkaraTurkey
| | - Alperen Baran
- Department of Molecular Biology and Genetics, Faculty of Scienceİhsan Doğramacı Bilkent UniversityAnkaraTurkey
| | - Khaled Warasnhe
- Department of PediatricsBaşkent University Faculty of MedicineAnkaraTurkey
| | - Şengül Beyaz
- Department of Immunology and Allergy DiseasesAnkara Bilkent City HospitalAnkaraTurkey
| | - Caner Aytekin
- Department of Pediatric ImmunologyDr. Sami Ulus Maternity and Children's Health and Diseases Training and Research HospitalAnkaraTurkey
| | - Figen Özçay
- Department of Pediatric Gastroenterology and HepatologyBaşkent University Faculty of MedicineAnkaraTurkey
| | - Yusuf Aydemir
- Department of Pediatric Gastroenterology, Faculty of MedicineEskişehir Osmangazi UniversityEskişehirTurkey
| | - Zeren Barış
- Department of Pediatric Gastroenterology, Faculty of MedicineEskişehir Osmangazi UniversityEskişehirTurkey
| | - Serkan Belkaya
- Department of Molecular Biology and Genetics, Faculty of Scienceİhsan Doğramacı Bilkent UniversityAnkaraTurkey
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7
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Nogueira AF, Teixeira C, Fernandes C, Moinho R, Gonçalves I, Pinto CR, Carvalho L. Prognostic Markers in Pediatric Acute Liver Failure. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2024; 31:165-172. [PMID: 38757064 PMCID: PMC11095588 DOI: 10.1159/000531269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 03/12/2023] [Indexed: 05/18/2024]
Abstract
Introduction Acute liver failure (ALF), although rare in children, is a complex progressive pathology, with multisystem involvement and high mortality. Isolated variables or those included in prognostic scores have been studied, to optimize organ allocation. However, its validation is challenging. This study aimed to assess the accuracy of several biomarkers and scores as predictors of prognosis in pediatric ALF (PALF). Methods An observational study with retrospective data collection, including all cases of ALF, was defined according to the criteria of the Pediatric Acute Liver Failure Study Group, admitted to a pediatric intensive care unit (PICU) for 28 years. Two groups were defined: spontaneous recovery (SR) and non-SR (NSR) - submitted to liver transplantation (LT) or death at PICU discharge. Results Fifty-nine patients were included, with a median age of 24 months, and 54% were female. The most frequent etiologies were metabolic (25.4%) and infectious (18.6%); 32.2% were undetermined. SR occurred in 21 patients (35.6%). In NSR group (N = 38, 64.4%), 25 required LT (42.4%) and 19 died (32.2%), 6 (15.7%) of whom after LT. The accuracy to predict NSR was acceptable for lactate at admission (AUC 0.72; 95% CI: 0.57-0.86; p = 0.006), ammonia peak (AUC 0.72; 95% CI: 0.58-0.86; p = 0.006), and INR peak (AUC 0.70; 95% CI: 0.56-0.85; p = 0.01). The cut-off value for lactate at admission was 1.95 mmol/L (sensitivity 78.4% and specificity 61.9%), ammonia peak was 64 μmol/L (sensitivity 100% and specificity 38.1%), and INR peak was 4.8 (sensitivity 61.1% and specificity 76.2%). Lactate on admission was shown to be an independent predictor of NSR on logistic regression model. Two prognostic scores had acceptable discrimination for NSR, LIU (AUC 0.73; 95% CI: 0.59-0.87; p = 0.004) and PRISM (AUC 0.71; 95% CI: 0.56-0.86; p = 0.03). In our study, the PALF delta score (PALF-ds) had lower discrimination capacity (AUC 0.63; 95% CI: 0.47-0.78; p = 0.11). Conclusions The lactate at admission, an easily obtained parameter, had a similar capacity than the more complex scores, LIU and PRISM, to predict NSR. The prognostic value in our population of the promising dynamic score, PALF-ds, was lower than expected.
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Affiliation(s)
- Andreia Filipa Nogueira
- Pediatric Intensive Care Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Catarina Teixeira
- Pediatric Intensive Care Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Carla Fernandes
- Pediatric Intensive Care Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Rita Moinho
- Pediatric Intensive Care Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Isabel Gonçalves
- Pediatric Liver Transplant and Hepatology Unit, Hospital Pediátrico, Coimbra, Portugal
| | - Carla Regina Pinto
- Pediatric Intensive Care Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- University Clinic of Pediatrics, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Leonor Carvalho
- Pediatric Intensive Care Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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8
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Squires JE, Horslen SP. Incorporation of genetic testing into the diagnostic algorithms of PALF: The time is now. Hepatology 2024; 79:970-972. [PMID: 38010272 DOI: 10.1097/hep.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 11/29/2023]
Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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9
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Ajmera A, Pernicone PJ, Patel N, Benabe SH. Coronavirus HKU1 infection and development of pediatric acute liver failure with immune dysregulation phenotype. JPGN REPORTS 2024; 5:204-207. [PMID: 38756108 PMCID: PMC11093931 DOI: 10.1002/jpr3.12065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 01/23/2024] [Accepted: 02/18/2024] [Indexed: 05/18/2024]
Abstract
Pediatric acute liver failure is a rare but serious complication of Coronavirus infections. Our patient is a previously healthy 8-year-old male who presented with acute liver failure in the setting of human coronavirus HKU1 (HCoV-HKU1) infection while asymptomatic from a respiratory perspective. During the hospital course, he developed acute hepatic encephalopathy and was listed for liver transplantation, but fortunately recovered remaining status 7 (inactive) on the transplant list. With a negative diagnostic evaluation other than his viral infection and hyperdense CD8 T-cells on liver immunohistochemical staining, pediatric acute liver failure (PALF) immune dysregulation phenotype was diagnosed.
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Affiliation(s)
- Arun Ajmera
- Center for Digestive Health and NutritionArnold Palmer Hospital for ChildrenOrlandoFloridaUSA
| | | | - Nishant Patel
- Center for Digestive Health and NutritionArnold Palmer Hospital for ChildrenOrlandoFloridaUSA
| | - Stefany Hernandez Benabe
- Advent Health Medical Group Pediatric Gastroenterology at OrlandoAdvent Health for ChildrenOrlandoFloridaUSA
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10
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Kaya S, Ekşi Bozbulut N. Therapeutic Plasma Exchange in Children With Acute and Acuteon-Chronic Liver Failure: A Single-Center Experience. EXP CLIN TRANSPLANT 2024; 22:88-95. [PMID: 38385381 DOI: 10.6002/ect.mesot2023.o12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVES Acute liver failure is a life-threatening condition that may result in death if liver transplant is not performed. The aim of our study was to evaluate patients with acute liver failure or acute-on-chronic liver failure who were followed and treated with therapeutic plasma exchange in a pediatric intensive care unit until they achieved clinical recovery or underwent liver transplant. MATERIALS AND METHODS In this retrospective, singlecenter study, we included patients with acute liver failure or acute-on-chronic liver failure who received therapeutic plasma exchange between April 2020 and December 2021. Clinical findings, laboratory findings, extracorporeal therapies, Pediatric Risk of Mortality III and liver injury unit scores and pretherapy and posttherapy hepatic encephalopathy scores, Model for End-Stage Liver Disease score, and Pediatric End-Stage Liver Disease score were retrospectively analyzed. RESULTS Nineteen patients were included in the study. One patient was excluded because of positivity for COVID-19. The mean age of children was 62.06 months, ranging from 5 months to 16 years (12 boys, 6 girls). Thirteen patients (72.2%) had acute liver failure, and 5 patients (27.8%) had acute-on-chronic liver failure. No significant difference was shown for mean liver injury unit score (P = .673) and Pediatric Logistic Organ Dysfunction score (P = .168) between patients who died and patients who received treatment at the inpatient clinic and transplant center. However, Pediatric Risk of Mortality score and the mean Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease scores before therapeutic plasma exchange and after therapeutic plasma exchange (after 3 consecutive days of treatment) were statistically significant (P = .001 and P = .004). CONCLUSIONS Therapeutic plasma exchange may assist bridge to liver transplant or assist with spontaneous recovery of liver failure in pediatric patients with acute liver failure or acute-on-chronic liver failure.
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Affiliation(s)
- Sadık Kaya
- From the Pediatric Intensive Care Unit, Hatay Research and Education Hospital, Hatay, Turkey
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11
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Hudry E, Aihara F, Meseck E, Mansfield K, McElroy C, Chand D, Tukov FF, Penraat K. Liver injury in cynomolgus monkeys following intravenous and intrathecal scAAV9 gene therapy delivery. Mol Ther 2023; 31:2999-3014. [PMID: 37515322 PMCID: PMC10556189 DOI: 10.1016/j.ymthe.2023.07.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/25/2023] [Accepted: 07/25/2023] [Indexed: 07/30/2023] Open
Abstract
Hepatotoxicity associated with intravenous/intrathecal adeno-associated virus (AAV) gene therapy has been observed in preclinical species and patients. In nonhuman primates, hepatotoxicity following self-complementary AAV9 administration varies from asymptomatic transaminase elevation with minimal to mild microscopic changes to symptomatic elevations of liver function and thromboinflammatory markers with microscopic changes consistent with marked hepatocellular necrosis and deteriorating clinical condition. These transient acute liver injury marker elevations occur from 3-4 days post intravenous administration to ∼2 weeks post intrathecal administration. No transaminase elevation or microscopic changes were observed with intrathecal administration of empty capsids or a "promoterless genome" vector, suggesting that liver injury after cerebrospinal fluid dosing in nonhuman primates is driven by viral transduction and transgene expression. Co-administration of prednisolone after intravenous or intrathecal dosing did not prevent liver enzyme or microscopic changes despite a reduction of T lymphocyte infiltration in liver tissue. Similarly, co-administration of rituximab/everolimus with intrathecal dosing failed to block AAV-driven hepatotoxicity. Self-complementary AAV-induced acute liver injury appears to correlate with high hepatocellular vector load, macrophage activation, and type 1 interferon innate virus-sensing pathway responses. The current work characterizes key aspects pertaining to early AAV-driven hepatotoxicity in cynomolgus macaques, highlighting the usefulness of this nonclinical species in that context.
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Affiliation(s)
- Eloise Hudry
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA.
| | - Fumiaki Aihara
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | - Emily Meseck
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936, USA
| | - Keith Mansfield
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | - Cameron McElroy
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936, USA
| | - Deepa Chand
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936, USA; Children's Hospital of Illinois, University of Illinois College of Medicine - Peoria, Peoria, IL 63110, USA
| | | | - Kelley Penraat
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
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12
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Rodriguez-Frias F, Rando-Segura A, Quer J. Solved the enigma of pediatric severe acute hepatitis of unknown origin? Front Cell Infect Microbiol 2023; 13:1175996. [PMID: 37808908 PMCID: PMC10552268 DOI: 10.3389/fcimb.2023.1175996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023] Open
Abstract
Hepatitis is an inflammation of the liver whose etiology is very heterogeneous. The most common cause of hepatitis is viral infections from hepatotropic viruses, including hepatitis A, B, C, D and E. However, other factors such as infections from other agents, metabolic disorders, or autoimmune reactions can also contribute to hepatitis, albeit to a lesser extent. On April 5, 2022, the United Kingdom Health Security Agency alerted the World Health Organization (WHO) on the increased incidence of severe acute hepatitis of unknown causes (not A-E) in previously healthy young children, with symptoms of liver failure that in some cases required liver transplantation. By July 2022, 1,296 cases were reported in 37 countries. Acute hepatitis of unknown causes is not an exceptional phenomenon: in fact, it represents more than 30% of cases of acute hepatitis in children, however in the present instance the large proportion of severe cases was surprising and alarming (6% of liver transplants and almost 3% mortality). Multiple hypotheses have been proposed to explain the etiology of such higher proportion of acute hepatitis, including their co-occurrence in the context of COVID-19 pandemic. This is a review of the history of a clinical threat that has put in check a world health care system highly sensitized by the current COVID-19 pandemics, and that it looks like has ended with the arguments that the severe acute pediatric hepatitis is caused by Adeno-associated virus 2 (AAV2) infection associated with a coinfection with a helper virus (human Adenovirus HAdV or human herpesvirus 6) in susceptible children carrying HLA-class II antigen HLA-DRB1*04:01.
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Affiliation(s)
- Francisco Rodriguez-Frias
- Clinical Biochemistry Department Vall d’Hebron Institut of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Basic Science Department, International University of Catalonia, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Ariadna Rando-Segura
- Clinical Biochemistry Department Vall d’Hebron Institut of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Josep Quer
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Liver Diseases-Viral Hepatitis, Liver Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Biochemistry and Molecular Biology Department, Autonomous University of Barcelona (UAB), Barcelona, Spain
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13
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Benevenuta C, Mussinatto I, Orsi C, Timeus FS. Secondary hemophagocytic lymphohistiocytosis in children (Review). Exp Ther Med 2023; 26:423. [PMID: 37602304 PMCID: PMC10433411 DOI: 10.3892/etm.2023.12122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 06/16/2023] [Indexed: 08/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening condition characterized by hyperinflammation in an uncontrolled and ineffective immune response. Despite great improvement in diagnosis and treatment, it still represents a challenge in clinical management, with poor prognosis in the absence of an aggressive therapeutic approach. The present literature review focuses on secondary HLH at pediatric age, which represents a heterogeneous group in terms of etiology and therapeutic approach. It summarizes the most recent evidence on epidemiology, pathophysiology, diagnosis, treatment and prognosis, and provides a detailed description and comparison of the major subtypes of secondary HLH. Finally, it addresses the open questions with a focus on diagnosis and new treatment insights.
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Affiliation(s)
- Chiara Benevenuta
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Ilaria Mussinatto
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Cecilia Orsi
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Fabio S. Timeus
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
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14
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Diamond T, Bennett AD, Behrens EM. The Liver in Hemophagocytic Lymphohistiocytosis: Not an Innocent Bystander. J Pediatr Gastroenterol Nutr 2023; 77:153-159. [PMID: 37098099 PMCID: PMC10524294 DOI: 10.1097/mpg.0000000000003807] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare multisystemic hyperinflammatory disease commonly associated with hepatic dysfunction. Liver injury is mediated by unchecked antigen presentation, hypercytokinemia, dysregulated cytotoxicity by natural killer and CD8 T cells, and disruption of intrinsic hepatic metabolic pathways. Over the past decade, there have been significant advances in diagnostics and expansion in therapeutic armamentarium for this disorder allowing for improved morbidity and mortality. This review discusses the clinical manifestations and pathogenesis of HLH hepatitis in both familial and secondary forms. It will review growing evidence that the intrinsic hepatic response to hypercytokinemia in HLH perpetuates disease progression and the novel therapeutic approaches for patients with HLH-hepatitis/liver failure.
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Affiliation(s)
- Tamir Diamond
- Division of Gastroenterology Hepatology and Nutrition, Children’s Hospital of Philadelphia
- Department of Pediatrics University of Pennsylvania
| | - Aaron D. Bennett
- Division of Gastroenterology Hepatology and Nutrition, Children’s Hospital of Philadelphia
| | - Edward M. Behrens
- Department of Pediatrics University of Pennsylvania
- Division of Rheumatology, Children’s Hospital of Philadelphia
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15
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Mandato C, Vajro P. Pediatric Acute Liver Failure. Pediatr Rep 2023; 15:426-430. [PMID: 37489413 PMCID: PMC10366751 DOI: 10.3390/pediatric15030039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 07/26/2023] Open
Abstract
Pediatric acute liver failure (PALF) has recently become a subject of great interest when multiple clusters of non-A to non-E severe acute hepatitis in otherwise healthy young children with a median age of 2 years were reported around the world [...].
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Affiliation(s)
- Claudia Mandato
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" University of Salerno, 84081 Baronissi, Salerno, Italy
| | - Pietro Vajro
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" University of Salerno, 84081 Baronissi, Salerno, Italy
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16
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Varadarajan P, Elilarasi S, Solomon RS, Subramani S, Subramanian R, Rangabashyam N, Srividya G. Multisystem Inflammatory Syndrome in Children (MIS-C) Associated With Covid-19 - Single-Center Experience. Indian Pediatr 2023; 60:389-390. [PMID: 36896751 PMCID: PMC10185933 DOI: 10.1007/s13312-023-2887-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/03/2022] [Accepted: 03/02/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVES To describe the clinical presentation, phenotype and outcome of multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (Covid-19) from a tertiary care center in southern India. METHODS 257 children fulfilling the inclusion criteria of MIS-C were prospectively enrolled from June, 2020 to March, 2022. RESULTS Median (range) age at presentation was 6 year (35 day to 12 years). Presenting features were fever (98%), vomiting (75.8%), red eyes (63%), rashes (49%), pain abdomen (49%), shock (45.9%), lymphopenia (73%, thrombocytopenia (58.3%) and anemia (45%). 103 (39.7%) children required intensive care admission. Shock phenotype, Kawasaki-like phenotype and no specific phenotype were diagnosed in 45.9%, 44.4%, and 36.6% children, respectively. Left ventricular dysfunction (30.3%), acute kidney injury (13%), acute liver failure (17.4%), and hemophagolymphohistiocytosis (HLH) (13.6%) were the major system involvement in MIS-C. Mitral regurgitation (P=0.029), hyperechogenic coronaries (P=0.006), Left ventricular dysfunction (P=0.001) and low ejection fraction (P=0.007) were significantly associated with shock. Overall mortality was 11.7%. CONCLUSION Kawasaki-like and shock-like presentation were common in MIS-C. Coronary abnormalities were seen in 118 (45.9%) children. Children with acute kidney injury, HLH, need for mechanical ventilation, and echocardiogram evidence of mitral regurgitation in MIS-C have a poor outcome.
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Affiliation(s)
- Poovazhagi Varadarajan
- Department of Pediatric Intensive Care, Institute of Child Health and Hospital for Children, Chennai, Tamil Nadu. Correspondence to: Dr Poovazhagi Varadarajan, HOD and Professor, Department of Pediatric Intensive Care, Institute of Child Health and Hospital for Children, Chennai, Tamil Nadu.
| | - S Elilarasi
- Department of Pediatric Pulmonology, Institute of Child Health and Hospital for Children, Chennai, Tamil Nadu
| | - Ritchie Sharon Solomon
- Department of Pediatric Cardiology, Institute of Child Health and Hospital for Children, Chennai, Tamil Nadu
| | - Seenivasan Subramani
- Department of Pediatric Intensive Care, Institute of Child Health and Hospital for Children, Chennai, Tamil Nadu
| | - Ramesh Subramanian
- Department of Pediatric Intensive Care, Institute of Child Health and Hospital for Children, Chennai, Tamil Nadu
| | - Nisha Rangabashyam
- Department of Pediatric Intensive Care, Institute of Child Health and Hospital for Children, Chennai, Tamil Nadu
| | - Gomathy Srividya
- Department of Pediatric Intensive Care, Institute of Child Health and Hospital for Children, Chennai, Tamil Nadu
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17
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Di Giorgio A, Gamba S, Sansotta N, Nicastro E, Colledan M, D'Antiga L. Identifying the Aetiology of Acute Liver Failure Is Crucial to Impact Positively on Outcome. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10040733. [PMID: 37189982 DOI: 10.3390/children10040733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/21/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
Management of children with acute liver failure is challenging. In this retrospective study, paediatric patients diagnosed with ALF at our centre, in the last 26 years, were divided into two groups (G1 = diagnosed from 1997 to 2009; G2 = from 2010 to 2022) and compared to see whether they differed with regard to aetiologies, need for liver transplantation (LT), and outcome. A total of 90 children (median age 4.6 years, range 1.2-10.4; M/F = 43/47) were diagnosed with ALF, by autoimmune hepatitis (AIH) in 16 (18%), paracetamol overdose in 10 (11%), Wilson disease in 8 (9%), and other causes in 19 (21%); 37 (41%) had indeterminate ALF (ID-ALF). Comparing the two periods, the clinical features, aetiologies, and median peak values of INR [3.8 (2.9-4.8) in G1 vs. 3.2 (2.4-4.8) in G2] were similar (p > 0.05). The percentage of ID-ALF tended to be higher in G1 compared to G2 (50% vs. 32% in G2, p = 0.09). The overall percentage of patients diagnosed with Wilson disease, inborn errors of metabolism, neonatal hemochromatosis or viral infection was higher in G2 (34% vs. 13% in G1, p = 0.02). A total of 21/90 patients (23%; 5 with indeterminate ALF) were treated with steroids; 12 (14%) required extracorporeal liver support treatment. The need for LT was significantly higher in G1 compared to G2 (56% vs. 34%; p = 0.032). Among 37 children with ID-ALF, 6 (16%) developed aplastic anaemia (all in G2, p < 0.001). The survival rate at last follow up was of 94%. On a KM curve, the transplant-free survival was lower in G1 compared to G2. In conclusion, we report a lower need for LT in children diagnosed with PALF during the most recent period compared to the first era. This suggests improvements over time in the diagnosis and management of children with PALF.
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Affiliation(s)
- Angelo Di Giorgio
- Paediatric Hepatology, Gastroenterology and Transplantation Department, ASST Hospital Papa Giovanni XXIII Bergamo, Piazza OMS 1, 24127 Bergamo, Italy
| | - Silvia Gamba
- Paediatric Hepatology, Gastroenterology and Transplantation Department, ASST Hospital Papa Giovanni XXIII Bergamo, Piazza OMS 1, 24127 Bergamo, Italy
| | - Naire Sansotta
- Paediatric Hepatology, Gastroenterology and Transplantation Department, ASST Hospital Papa Giovanni XXIII Bergamo, Piazza OMS 1, 24127 Bergamo, Italy
| | - Emanuele Nicastro
- Paediatric Hepatology, Gastroenterology and Transplantation Department, ASST Hospital Papa Giovanni XXIII Bergamo, Piazza OMS 1, 24127 Bergamo, Italy
| | - Michele Colledan
- Department of Organ Failure and Transplantation, Surgery University Milano-Bicocca, ASST Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Lorenzo D'Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation Department, ASST Hospital Papa Giovanni XXIII Bergamo, Piazza OMS 1, 24127 Bergamo, Italy
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18
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Pediatric acute liver failure in Saudi Arabia: prognostic indicators, outcomes and the role of genetic testing. Eur J Gastroenterol Hepatol 2023; 35:420-430. [PMID: 36574286 DOI: 10.1097/meg.0000000000002499] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
OBJECTIVE The objective of this study was to determine the etiologies, outcomes, prognostic indicators and the role of genetic testing in children with acute liver failure (ALF). METHODS This retrospective study included 46 patients with pediatric acute liver failure (PALF) according to the PALF study group definition, admitted to King Fahad Specialist Hospital-Dammam, Saudi Arabia, between January 2014 and December 2021. Patients who survived with supportive therapy were designated as the recovery group, whereas those who died or underwent liver transplantation were designated as the death/transplant group. RESULTS There were 26 (56.5%) patients in the recovery group and 20 (43.5%) patients in the death/transplant group. Four patients (8.7%) underwent liver transplantation. After indeterminate causes (45.6%), genetic-metabolic diseases and drug-induced liver injury (DILI) were the most common cause with 15.2 and 13%, respectively. Genetic testing had a high yield of (6/31) in identifying monogenic disease associated with ALF. Younger age, lower Glasgow Coma Scale and higher international normalized ratio (INR) on admission were predictors for poor prognosis. The death/transplant group had longer intensive care unit stay ( P < 0.001), and on admission they had more advanced hepatic encephalopathy ( P < 0.005), more prolonged prothrombin time ( P < 0.001), higher lactate ( P < 0.006), higher total and direct bilirubin ( P < 0.008) and ( P < 0.001), respectively. CONCLUSION Genetic, metabolic and DILI causes constituted the most common cause of PALF after indeterminate causes. The use of genetic testing can improve diagnostic rates in special cases, but we could not assess the effect of genetic testing on prognosis. The overall survival rate in our study was 65.2%. Younger age, higher admission INR and lower Glasgow coma scale were indicators of poor prognosis.
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19
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Mann JP, Lenz D, Stamataki Z, Kelly D. Common mechanisms in pediatric acute liver failure. Trends Mol Med 2023; 29:228-240. [PMID: 36496278 DOI: 10.1016/j.molmed.2022.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/06/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022]
Abstract
Acute liver failure (ALF) is a rare but potentially fatal disease in children. The etiology is multifactorial, including infection, autoimmune, and genetic disorders, as well as indeterminate hepatitis, which has a higher requirement for liver transplantation. Activation of the innate and adaptive immune systems leads to hepatocyte-specific injury which is mitigated by T regulatory cell activation. Recovery of the native liver depends on activation of apoptotic and regenerative pathways, including the integrated stress response (ISR; e.g., PERK), p53, and HNF4α. Loss-of-function mutations in these pathways cause recurrent ALF in response to non-hepatotropic viruses. Deeper understanding of these mechanisms will lead to improved diagnosis, management, and outcomes for pediatric ALF.
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Affiliation(s)
- Jake P Mann
- Liver Unit, Birmingham Women's and Children's Hospital, and University of Birmingham, Birmingham, UK
| | - Dominic Lenz
- Division of Neuropediatrics and Pediatric Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Zania Stamataki
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Deirdre Kelly
- Liver Unit, Birmingham Women's and Children's Hospital, and University of Birmingham, Birmingham, UK; Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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20
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Gong K, Xu X, Yao J, Ye S, Yu X, Tu H, Lan Y, Fan YC, Shi Y. Acute hepatitis of unknown origin in children: A combination of factors. Front Pharmacol 2022; 13:1056385. [PMID: 36438816 PMCID: PMC9698116 DOI: 10.3389/fphar.2022.1056385] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/31/2022] [Indexed: 08/16/2023] Open
Abstract
On 5 April 2022, the World Health Organization was notified of 10 cases of severe acute hepatitis of unknown etiology in children under 10 years of age in the United Kingdom. Although the exact cause of a proportion of pediatric acute hepatitis and acute liver failure cases was unclear, the above event has caused widespread concern worldwide. As of 14 September 2022, approximately 1,296 probable cases of acute hepatitis of unknown etiology have been reported from 37 countries/regions, of which approximately 55 required or received liver transplantation and 29 died. Although the etiology of acute hepatitis of unknown origin in children remains unclear, many hypotheses have been proposed about the disease. Instead of individual factors such as "adenovirus infection," "SARS-CoV-2 related," and "Adeno-associated virus 2 with helper virus coinfection," it is more likely due to a combination of factors. Accordingly, there is an urgent need for more data and research to clarify the disease etiology. This review aims to provide a historical perspective of acute hepatitis of unknown etiology in children in the past decades and summarize the current hypothesis and evidence on this emerging disease.
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Affiliation(s)
- Kai Gong
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xianbin Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Junjie Yao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shaoheng Ye
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xia Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Huilan Tu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yan Lan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yu-chen Fan
- Department of Hepatology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Yu Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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21
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Wang LC, Tsai HP, Chen SH, Wang SM. Therapeutics for fulminant hepatitis caused by enteroviruses in neonates. Front Pharmacol 2022; 13:1014823. [DOI: 10.3389/fphar.2022.1014823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022] Open
Abstract
Neonatal infection with nonpolio enteroviruses (EVs) causes nonspecific febrile illnesses and even life-threatening multiorgan failure. Hepatitis, which often results in hepatic necrosis followed by disseminated intravascular coagulopathy, is one of the most severe and frequent fatal neonatal EV infection complications. Coxsackievirus B (CVB) 1–5 and many echoviruses have been most commonly identified. Neonatal EV infection treatment has usually involved initial supportive care. Studies for CVB and echovirus infection treatments were developed for more than thirty years. Intravenous immunoglobulin and pleconaril therapy was performed in some clinical trials. Additionally, other studies demonstrated antiviral and/or anti-inflammatory pathogenesis mechanisms of neonatal EV hepatitis in in vitro or in vivo models. These treatments represented promising options for the clinical practice of neonatal EV hepatitis. However, further investigation is needed to elucidate the whole therapeutic potential and safety problems.
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22
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Acute Hepatitis of Unknown Etiology Among Young Children: Research Agenda by the ESPGHAN Hepatology Committee. J Pediatr Gastroenterol Nutr 2022; 75:543-548. [PMID: 35848740 DOI: 10.1097/mpg.0000000000003567] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In April 2022, an increased incidence of acute hepatitis cases of unknown etiology among previously healthy children across the United Kingdom was described. Since, more than 270 cases from the United Kingdom and hundreds more from all across the world have been reported. The majority of affected children were younger than 6 years of age. The clinical presentation was nonspecific with diarrhea and vomiting usually preceding the appearance of jaundice, abdominal pain, nausea, and malaise. Approximately 5% have required liver transplantation. An infectious etiology has been considered likely given the epidemiological and clinical features of the reported cases. Between 50 and 60% of the children tested were diagnosed with adenovirus infection although a clear etiological connection has still to be demonstrated. No link with SARS-CoV-2 infection and COVID-19 vaccine was found. What is not clear to date is whether the high number of acute hepatitis cases reported is related to a true increase in incidence or heightened awareness following on from the initial reports from the United Kingdom. The Hepatology Committee of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) developed a paper on the current outbreak of acute hepatitis of unknown etiology recognizing its importance and the need of approaching the current situation with a scientifically rigorous approach. The aims of the article are to summarize the current knowledge and to identify the most pertinent issues regarding the diagnosis and management of this condition and the research questions raised.
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23
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Kulkarni S, Chapin CA, Alonso EM, Rudnick DA. An Update on Pediatric Acute Liver Failure: Emerging Understanding of the Impact of Immune Dysregulation and Novel Opportunities for Intervention. Clin Liver Dis 2022; 26:461-471. [PMID: 35868685 DOI: 10.1016/j.cld.2022.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Pediatric acute liver failure (PALF) is a complex, unpredictable, often rapidly progressive, potentially devastating clinical syndrome that occurs in infants, children, and adolescents without pre-existing liver disease. PALF is characterized by acute onset of hepatocellular injury and liver-based coagulopathy, frequently accompanied by hepatic encephalopathy. Etiologies include drug and toxin exposures, metabolic and genetic disorders, infections, and immune-mediated disease. PALF management primarily involves early contact with and consideration of transfer to a pediatric liver transplant center and intensive supportive multidisciplinary clinical care, with targeted therapies available for a subset of causes. Outcomes include survival with native liver, death, and liver transplantation. Efforts to develop reliable clinical prognostic tools to predict PALF outcomes early in the course of disease have not yet been fulfilled, and the possibility remains that some transplanted PALF patients might have survived without transplantation.
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Affiliation(s)
- Sakil Kulkarni
- Department of Pediatrics, St. Louis Children's Hospital, One Children's Place, St Louis, MO 63110, USA
| | - Catherine A Chapin
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Box 65, 225 E Chicago Avenue, Chicago, IL 60611, USA
| | - Estella M Alonso
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Box 65, 225 E Chicago Avenue, Chicago, IL 60611, USA
| | - David A Rudnick
- Department of Pediatrics, St. Louis Children's Hospital, One Children's Place, St Louis, MO 63110, USA; Department of Developmental Biology, Washington University School of Medicine, 3105 McDonnell Pediatric Research Building, 660 S Euclid Avenue, Campus Box 8208, St Louis, MO 63110, USA.
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24
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Romaní Vidal A, Vaughan A, Innocenti F, Colombe S, Nerlander L, Rachwal N, Ciancio BC, Mougkou A, Carvalho C, Delgado E, Mook P, de Muylder G, Peeters M, Tenev T, Golkocheva-Markova E, Vorobieva Solholm Jensen V, Koch A, Figoni J, Brouard C, Nikolopoulou G, Zisouli A, Murphy N, Broderick A, Goldberg L, Rich R, Hecht Sagie L, Tosti ME, Suligoi B, Joosten R, Pijnacker R, Fjeldheim I, Heen E, Stępień M, Polański P, Tato Marinho R, Vieira Martins J, Varela C, Avellón A, Andersson E, Jansson Mörk M, Mandal S, Watson C, Coughlan L, Chand M, Neill C, Bradley DT, Li K, O'Leary M, McInnes N, Williams CJ, Moore C, Gjini A, Duffell E, Pebody R. Hepatitis of unknown aetiology in children - epidemiological overview of cases reported in Europe, 1 January to 16 June 2022. EURO SURVEILLANCE : BULLETIN EUROPEEN SUR LES MALADIES TRANSMISSIBLES = EUROPEAN COMMUNICABLE DISEASE BULLETIN 2022; 27. [PMID: 35929429 PMCID: PMC9358403 DOI: 10.2807/1560-7917.es.2022.27.31.2200483] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Following the report of an excess in paediatric cases of severe acute hepatitis of unknown aetiology by the United Kingdom (UK) on 5 April 2022, 427 cases were reported from 20 countries in the World Health Organization European Region to the European Surveillance System TESSy from 1 January 2022 to 16 June 2022. Here, we analysed demographic, epidemiological, clinical and microbiological data available in TESSy. Of the reported cases, 77.3% were 5 years or younger and 53.5% had a positive test for adenovirus, 10.4% had a positive RT-PCR for SARS-CoV-2 and 10.3% were coinfected with both pathogens. Cases with adenovirus infections were significantly more likely to be admitted to intensive care or high-dependency units (OR = 2.11; 95% CI: 1.18–3.74) and transplanted (OR = 3.36; 95% CI: 1.19–9.55) than cases with a negative test result for adenovirus, but this was no longer observed when looking at this association separately between the UK and other countries. Aetiological studies are needed to ascertain if adenovirus plays a role in this possible emergence of hepatitis cases in children and, if confirmed, the mechanisms that could be involved.
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Affiliation(s)
| | - Aisling Vaughan
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Francesco Innocenti
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.,Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy
| | - Soledad Colombe
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Lina Nerlander
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Natalia Rachwal
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | | | - Aikaterini Mougkou
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Carlos Carvalho
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Enrique Delgado
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Piers Mook
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | | | - Michael Peeters
- Sciensano, Infectious Diseases in Humans, Viral Diseases, National Reference Centre for Hepatitis Viruses, Brussels, Belgium
| | - Tencho Tenev
- National Reference Laboratory Hepatitis viruses, NCIPD-Virology, Sofia, Bulgaria
| | | | | | - Anders Koch
- Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - Julie Figoni
- Santé Publique France, the National Public Health Agency, Saint-Maurice, France
| | - Cécile Brouard
- Santé Publique France, the National Public Health Agency, Saint-Maurice, France
| | | | | | - Niamh Murphy
- Health Service Executive HPSC surveillance scientist on the National IMT for hepatitis, Dublin, Ireland
| | | | | | - Rivka Rich
- Israel Ministry of Health, Jerusalem, Israel
| | | | - Maria Elena Tosti
- National Centre for Global Health - Istituto Superiore di Sanità, Rome, Italy
| | - Barbara Suligoi
- Infectious Disease Department - Istituto Superiore di Sanità, Rome, Italy
| | - Rosa Joosten
- National Institute for Public Health and the Environment (RIVM), Centre for Infectious Disease Control, Bilthoven, the Netherlands
| | - Roan Pijnacker
- National Institute for Public Health and the Environment (RIVM), Centre for Infectious Disease Control, Bilthoven, the Netherlands
| | - Ingvild Fjeldheim
- Department of Infection Control and Vaccines, Norwegian Institute of Public Health, Oslo, Norway
| | - Eli Heen
- Department of Infection Control and Vaccines, Norwegian Institute of Public Health, Oslo, Norway
| | - Małgorzata Stępień
- Department of Epidemiology of Infectious Diseases and Surveillance, National Institute of Public Health NIH - National Research Institute, Warsaw, Poland
| | - Piotr Polański
- Department of Epidemiology of Infectious Diseases and Surveillance, National Institute of Public Health NIH - National Research Institute, Warsaw, Poland
| | - Rui Tato Marinho
- Gastroenterology and Hepatology Department, Hospital S. Maria; Medical School of Lisbon; National Programme for Viral Hepatitis, Portugal Ministry of Health, Lisbon, Portugal
| | - João Vieira Martins
- Directorate of Information and Analysis, Directorate-General of Health, Lisbon, Portugal
| | - Carmen Varela
- National Centre of Epidemiology, Carlos III Institute of Health, CIBERESP, Madrid, Spain
| | - Ana Avellón
- National Centre of Microbiology, Carlos III Institute of Health, CIBERESP, Madrid, Spain
| | | | | | - Sema Mandal
- United Kingdom Health Security Agency Epidemiology Cell, London, United Kingdom
| | - Conall Watson
- United Kingdom Health Security Agency Epidemiology Cell, London, United Kingdom
| | - Laura Coughlan
- United Kingdom Health Security Agency Epidemiology Cell, London, United Kingdom
| | - Meera Chand
- United Kingdom Health Security Agency Incident Director, London, United Kingdom
| | - Claire Neill
- Public Health Agency Northern Ireland, Belfast, United Kingdom
| | | | - Kathy Li
- Regional Virology Laboratory Belfast Health and Social Care Trust, Northern Ireland, Belfast, United Kingdom
| | - Maureen O'Leary
- Clinical and Protecting Health Directorate, Public Health Scotland, Glasgow, United Kingdom
| | - Neil McInnes
- West of Scotland Specialist Virology Centre, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | | | | | | | - Erika Duffell
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Richard Pebody
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
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25
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Safety of Onasemnogene Abeparvovec for Patients With Spinal Muscular Atrophy 8.5 kg or Heavier in a Global Managed Access Program. Pediatr Neurol 2022; 132:27-32. [PMID: 35605311 DOI: 10.1016/j.pediatrneurol.2022.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/18/2022] [Accepted: 05/02/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Spinal muscular atrophy is a rare, neurodegenerative disorder caused by biallelic deletions in the survival motor neuron (SMN1) gene. Onasemnogene abeparvovec is a one-time, intravenous gene replacement therapy designed to deliver the SMN1 transgene. Although available in many geographies, it is not approved globally. The Global Managed Access Program (GMAP) expanded treatment access to patients in countries where treatment was not approved. Previous onasemnogene abeparvovec clinical trials included patients with body weight <8.5 kg. Through GMAP, children weighing ≥8.5 kg received onasemnogene abeparvovec. We describe safety data for heavier patients in GMAP. METHODS GMAP records were reviewed to identify patients weighing ≥8.5 kg at onasemnogene abeparvovec dosing. To obtain corresponding adverse event (AE) data, the Novartis ARGUS safety database was searched using patient identification numbers and birth dates/dosing dates for any reported AE for GMAP patients. RESULTS As of September 2, 2021, 102 patients weighing ≥8.5 kg at time of dosing were identified. Fifty-four (53%) had one or more reported AEs. Three patients were reported to be deceased. All three deaths were assessed to be secondary to acute respiratory events. Most (62%) AEs were non-serious. The most frequently reported AEs included increases in hepatic laboratory values, decreased platelets and thrombocytopenia, pyrexia, vomiting, and decreased appetite. CONCLUSIONS Safety findings for patients weighing ≥8.5 kg administered onasemnogene abeparvovec through GMAP were consistent with those described in clinical trials and included hepatotoxicity, thrombotic microangiopathy, and thrombocytopenia.
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26
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Abstract
Pediatric acute liver failure (PALF) is a life-threatening disorder characterized by acute hepatocellular injury occurring in children without recognized underlying liver disease. The clinicopathologic evaluation of PALF requires a different approach from that in adults. The diagnostic considerations differ depending on the age, personal and family history, geographical region, and clinical presentation. Distinct entities such as gestational alloimmune liver disease, herpes simplex virus infection, and metabolic disorders should be considered in neonates with acute liver failure, while acetaminophen toxicity and autoimmune hepatitis are more frequently seen in older children and adolescents. An identified cause for PALF despite a negative complete evaluation (indeterminate) is lacking in 30 to 50% of cases. Although not routinely performed in the setting of PALF, liver biopsy may be helpful in assessing the etiology, potential mechanisms of injury, determining the appropriateness of liver transplantation, and prognostication of the patients. In this article, we review the clinicopathologic characteristics of PALF with an emphasis on general approach of pathologic evaluation and histopathologic characteristic of selected entities.
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Affiliation(s)
- Juan Putra
- Division of Pathology, Department of Paediatric Laboratory Medicine, 7979The Hospital for Sick Children, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Vicky L Ng
- Division of Gastroenterology, Hepatology, and Nutrition, 7979The Hospital for Sick Children, Toronto, ON, Canada
| | - Antonio R Perez-Atayde
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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27
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Abstract
Acute liver failure (ALF) in children, irrespective of cause, is a rapidly evolving catastrophic clinical condition that results in high mortality and morbidity without prompt identification and intervention. Massive hepatocyte necrosis impairs the synthetic, excretory, and detoxification abilities of the liver, with resultant coagulopathy, jaundice, metabolic disturbance, and encephalopathy. Extrahepatic organ damage, multiorgan failure, and death result from circulating inflammatory mediators released by the hepatocytes undergoing necrosis. There are yet no treatment options available for reversing or halting hepatocellular necrosis, thus current therapy focuses on supporting failing organs and preventing life threatening complications pending either spontaneous liver recovery or transplantation. The aims of this review are to define pediatric acute liver failure (PALF), understand the pathophysiologic processes that lead to multiorgan failure, to describe the consequences of a failing liver on extrahepatic organs, to enumerate the critical care challenges encountered during PALF management, and to describe pharmacologic and extracorporeal options available to support a critically ill child with ALF in the intensive care unit.
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Affiliation(s)
- Divya G Sabapathy
- Department of Pediatrics, Division of Pediatric Critical Care Medicine and Liver ICU, Baylor College of Medicine, 1, Baylor Plaza, Houston, TX 77030, USA
| | - Moreshwar S Desai
- Department of Pediatrics, Division of Pediatric Critical Care Medicine and Liver ICU, Baylor College of Medicine, 1, Baylor Plaza, Houston, TX 77030, USA.
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28
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Ide K, Uchida H, Sakamoto S, Nishimura N, Nakagawa S, Kobayashi T, Ito S, Kasahara M. Neurological impairment in children with acute liver failure following liver transplantation-A single-center experience. Pediatr Transplant 2022; 26:e14240. [PMID: 35132740 DOI: 10.1111/petr.14240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/01/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although overall survival of ALF has improved, neurological restoration after recovery from ALF may not always be satisfactory. The purpose of this study was to investigate the occurrence and possible causes of NI in children with ALF following LT. METHODS We retrospectively examined all children younger than 16 years old with ALF who subsequently underwent LT at our center between January 2005 and December 2016. NI was assessed in December 2016 using the six-point Pediatric Cerebral Performance Category score and was defined as any increase in the score. RESULTS There were 62 children with median age 10 months (quartile range 5-34). The etiology of ALF was indeterminate in 47 children (75.8%). The median duration from admission to LT was 5.5 days (quartile range 4-7), and 96.8% (60/62) received living donor LT. The overall survival was 83.9% (52/62) in a median follow-up period of 4.2 years. Mild-to-moderate NI was observed in 23.1% (12/52) of the survivors. Possible causes of NI were underlying systemic disease (n = 3), perioperative brain lesion (n = 2), and unclassified (n = 7). All seven patients with unclassified NI were less than 12 months old. The unclassified NI causes were presumed to be ALF, its perioperative care, and the vulnerable infant brain. CONCLUSIONS NI in children with ALF following LT was not rare and should be prevented. Further investigations are required to clarify the characteristics of the patients with unclassified NI.
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Affiliation(s)
- Kentaro Ide
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan.,Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Nao Nishimura
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Tohru Kobayashi
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Clinical Research Center, Department of Data Science, National Center for Child Health and Development, Tokyo, Japan
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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29
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Arnal IR, Andrade JR, Hally MM, Baviera LCB, Tirado DG, Martín SHC, de la Calle Navarro E, Álvarez AMV. Diagnostic action against hypertransaminasemia in paediatrics: Consensus document of Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediátrica (SEGHNP), Asociación Española de Pediatría de Atención Primaria (AEPap) and Sociedad Española de Pediatría de Atención Primaria (SEPEAP). ANALES DE PEDIATRÍA (ENGLISH EDITION) 2022; 96:448.e1-448.e11. [DOI: 10.1016/j.anpede.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 04/07/2022] [Indexed: 02/07/2023] Open
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30
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Actuación diagnóstica ante hipertransaminasemia en pediatría: documento de consenso de Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediátrica (SEGHNP), Asociación Española de Pediatría de Atención Primaria (AEPap) y Sociedad Española de Pediatría de Atención Primaria (SEPEAP). An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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31
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Massabki LHP, Sandy NS, De Tommaso AMA, Brandão MAB, Hessel G, Lomazi EA. Pediatric Acute Liver Failure as Presentation of Autoimmune Hepatitis: Learning from a Fatal Case. JPGN REPORTS 2022; 3:e151. [PMID: 37168764 PMCID: PMC10158326 DOI: 10.1097/pg9.0000000000000151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/28/2021] [Indexed: 05/13/2023]
Abstract
Severe acute liver failure (SALF) is a rare condition in children. Up to 50% of the cryptogenic causes of SALF are associated with autoimmune hepatitis (AIH). This report presents a 5-year-old girl with progressive jaundice for 10 days. Her 1999 AIH diagnostic score totaled 11 points, compatible with probable AIH. She fulfilled the SALF criteria and the King's College criteria for liver transplantation, despite treatment with corticosteroids, and underwent the transplant, but died in the immediate postoperative period due to massive bleeding. Subsequently, the liver-kidney microsome type 1 result was 1:80, increasing the AIH score to 13 points. The final diagnosis was probable AIH type 2, associated with SALF. The biopsy of the explanted liver was compatible with fulminant hepatitis. This report highlights the difficult diagnosis of AIH in SALF, limitations of the diagnostic criteria for SALF in indications for emergency transplantation, and the uncertain therapeutic response produced by corticosteroids.
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Affiliation(s)
- Lilian H. P. Massabki
- From the Pediatric Gastroenterology, Hepatology and Nutrition at University of Campinas, School of Medical Sciences, Campinas, São Paulo, Brazil
| | - Natascha S. Sandy
- Pediatric Gastroenterology, Hepatology and Nutrition at The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Adriana M. A. De Tommaso
- Department of Pediatrics at University of Campinas, School of Medical Sciences, Campinas, São Paulo, Brazil
| | - Maria A. B. Brandão
- Department of Pediatrics at University of Campinas, School of Medical Sciences, Campinas, São Paulo, Brazil
| | - Gabriel Hessel
- Department of Pediatrics at University of Campinas, School of Medical Sciences, Campinas, São Paulo, Brazil
| | - Elizete A. Lomazi
- Department of Pediatrics at University of Campinas, School of Medical Sciences, Campinas, São Paulo, Brazil
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32
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Yang CF, Liu JW, Jin LM, Li YM. Association of duration and etiology with the effect of the artificial liver support system in pediatric acute liver failure. Front Pediatr 2022; 10:951443. [PMID: 36340721 PMCID: PMC9632289 DOI: 10.3389/fped.2022.951443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We aimed to assess the efficacy of the artificial liver support system (ALSS) in pediatric acute liver failure (PALF) patients and to examine the risk factors associated with the effect of ALSS. Similar data are limited in PALF. METHODS All patients diagnosed with PALF who received ALSS from June 2011 to June 2021 in the pediatric intensive care unit of the First Hospital of Jilin University were included in this retrospective cohort analysis. The effect of ALSS was measured using difference tests before and after treatments. The risk factors associated with the effect of ALSS were evaluated according to whether the total bilirubin (TBIL) and serum ammonia decreased after ALSS (TBIL-unresponsive group vs. TBIL-responsive group, serum ammonia-unresponsive group vs. serum ammonia-responsive group). RESULTS Thirty-nine patients who received ALSS during the study period were eligible for inclusion. The most common cause of PALF was undetermined causes (n = 14, 35.9%) followed by infection (n = 11, 28.2%). Four patients received pediatric liver transplantation. The overall survival rate was 76.9% (30/39). Fifteen (38.4%) patients received only one modality, whereas 61.6% patients received hybrid treatments. The most commonly used modality of ALSS was plasma exchange combined with continuous renal replacement therapy (n = 14, 35.9%). Alanine aminotransferase, TBIL, the international normalized ratio, and serum ammonia were significantly decreased after ALSS (P < 0.001). Compared with other causes, more patients with infection and toxication were observed in the TBIL-unresponsive group. A longer ALSS duration was significantly related to blood ammonia reduction. CONCLUSIONS ALSS can effectively reduce serum alanine aminotransferase, TBIL, international normalized ratio, and serum ammonia and may reduce mortality. The reduction in TBIL levels after ALSS is dependent on etiology. A longer ALSS duration was associated with blood ammonia reduction. Prospective multicenter studies are needed for further validation.
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Affiliation(s)
- Chun-Feng Yang
- Department of Pediatric Intensive Care Unit, First Hospital of Jilin University, Changchun, China
| | - Jing-Wei Liu
- Department of Pediatric Intensive Care Unit, First Hospital of Jilin University, Changchun, China
| | - Lin-Mei Jin
- Department of Pediatric Intensive Care Unit, First Hospital of Jilin University, Changchun, China
| | - Yu-Mei Li
- Department of Pediatric Intensive Care Unit, First Hospital of Jilin University, Changchun, China
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33
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Amatya P, Kapalavai SK, Deep A, Sankaranarayanan S, Krupanandan R, Sadasivam K, Ramachandran B. Pediatric acute liver failure: An experience of a pediatric intensive care unit from resource limited settings. Front Pediatr 2022; 10:956699. [PMID: 36120651 PMCID: PMC9478462 DOI: 10.3389/fped.2022.956699] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/12/2022] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Pediatric acute liver failure is a rare and serious disease. Though liver transplantation is considered as the established treatment option for patients who are unlikely to recover with medical management, however, with the advancement of medical care there has been an increase in spontaneous regeneration of liver, obviating the need for liver transplantation. We identified the etiologies, outcome and prognostic factors of acute liver failure and the validity of the existing liver transplantation criteria to predict the outcome of pediatric acute liver failure. MATERIALS AND METHODS This was a retrospective study done from January 2014 to December 2019 in a tertiary pediatric critical care unit in South India. All children aged between 1 month to 18 years admitted with acute liver failure were enrolled. RESULTS Of 125 children with acute liver failure, the main etiologies were infections (32%), indeterminate (23%), paracetamol toxicity (21%), metabolic (13%) and others (11%). Dengue was the most common infection (55%). The median pediatric logistic organ dysfunction score at admission was 12 (4-27). Of 125 patients, 63.2% (n = 79) had spontaneous regeneration which was higher in paracetamol induced (92.3%) compared to non-paracetamol induced acute liver failure (55.5%). Only two patients underwent liver transplantation and 35% died. Peak alanine transaminase and use of inotropes significantly predicted the outcome of disease. Of 38 children meeting King's College Hospital criteria for liver transplantation, 57.9% had spontaneous regeneration and 36.8% died. Of 74 children meeting INR > 4 criteria, 54% (n = 40) had spontaneous regeneration and 43.2% died. INR >4 criteria was more sensitive than King's College Hospital criteria for predicting the need for liver transplantation. CONCLUSION Pediatric acute liver failure is caused by varied etiologies and infections were the commonest cause. Despite having a seriously ill cohort of patients, medical management resulted in spontaneous regeneration in the majority of children with acute liver failure. The use of inotropes, advanced hepatic encephalopathy, and peak alanine transaminase were predictors of poor outcome in children with acute liver failure and these patients could be considered for liver transplantation as available. Therefore, we may need to develop better predictors of pediatric acute liver failure in resource limited settings.
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Affiliation(s)
- Puja Amatya
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Sudeep Kumar Kapalavai
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Akash Deep
- Department of Pediatric Critical Care, King's College Hospital, London, United Kingdom
| | | | - Ravikumar Krupanandan
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Kalaimaran Sadasivam
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Bala Ramachandran
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
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34
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Squires JE, Alonso EM, Ibrahim SH, Kasper V, Kehar M, Martinez M, Squires RH. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr 2022; 74:138-158. [PMID: 34347674 DOI: 10.1097/mpg.0000000000003268] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACT Pediatric acute liver failure (PALF) is a rare, rapidly progressive clinical syndrome with significant morbidity and mortality. The phenotype of PALF manifests as abrupt onset liver dysfunction, which can be brought via disparate etiology. Management is reliant upon intensive clinical care and support, often provided by the collaborative efforts of hepatologists, critical care specialists, and liver transplant surgeons. The construction of an age-based diagnostic approach, the identification of a potential underlying cause, and the prompt implementation of appropriate therapy can be lifesaving; however, the dynamic and rapidly progressive nature of PALF also demands that diagnostic inquiries be paired with monitoring strategies for the recognition and treatment of common complications of PALF. Although liver transplantation can provide a potential life-saving therapeutic option, the ability to confidently determine the certainness that liver transplant is needed for an individual child has been hampered by a lack of adequately tested clinical decision support tools and accurate predictive models. Given the accelerated progress in understanding PALF, we will provide clinical guidance to pediatric gastroenterologists and other pediatric providers caring for children with PALF by presenting the most recent advances in diagnosis, management, pathophysiology, and associated outcomes.
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Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Estella M Alonso
- Department Pediatric Hepatology, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois, USA
| | - Samar H Ibrahim
- Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vania Kasper
- Division of Pediatric Gastroenterology, Nutrition and Liver Diseases, Hasbro Children's Hospital, Providence, RI
| | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Mercedes Martinez
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Robert H Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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35
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Abstract
The recent increase in unexplained acute hepatitis in children in 2022 has focused attention on acute paediatric liver disease. We discuss emerging evidence and leading causal hypotheses in context with potential long-term effects of the COVID-19 pandemic for young children.
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36
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Insuficienţă hepatică acută asociată cu infecţie recentă cu SARS-CoV-2 la un copil – prezentare de caz. PEDIATRU.RO 2022. [DOI: 10.26416/pedi.65.1.2022.6336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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37
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Raja RA, Wolthers BO, Frandsen TL, Albertsen BK, Schulz N, Damholt MB, Schmiegelow K, Jørgensen MH. Acute liver failure in a four-year old girl during maintenance therapy of acute lymphoblastic leukemia. Pediatr Hematol Oncol 2021; 38:669-675. [PMID: 33798035 DOI: 10.1080/08880018.2021.1906800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- R A Raja
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - B O Wolthers
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - T L Frandsen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - B K Albertsen
- Children and Adolescent Health, Aarhus University Hospital, Aarhus, Denmark
| | - N Schulz
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - M B Damholt
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - K Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - M H Jørgensen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Hegarty R, Gibson P, Sambrotta M, Strautnieks S, Foskett P, Ellard S, Baptista J, Lillis S, Bansal S, Vara R, Dhawan A, Grammatikopoulos T, Thompson RJ. Study of Acute Liver Failure in Children Using Next Generation Sequencing Technology. J Pediatr 2021; 236:124-130. [PMID: 34023347 DOI: 10.1016/j.jpeds.2021.05.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/14/2021] [Accepted: 05/14/2021] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To use next generation sequencing (NGS) technology to identify undiagnosed, monogenic diseases in a cohort of children who suffered from acute liver failure (ALF) without an identifiable etiology. STUDY DESIGN We identified 148 under 10 years of age admitted to King's College Hospital, London, with ALF of indeterminate etiology between 2000 and 2018. A custom NGS panel of 64 candidate genes known to cause ALF and/or metabolic liver disease was constructed. Targeted sequencing was carried out on 41 children in whom DNA samples were available. Trio exome sequencing was performed on 4 children admitted during 2019. A comparison of the clinical characteristics of those identified with biallelic variants against those without biallelic variants was then made. RESULTS Homozygous and compound heterozygous variants were identified in 8 out of 41 children (20%) and 4 out of 4 children (100%) in whom targeted and exome sequencing were carried out, respectively. The genes involved were NBAS (3 children); DLD (2 children); and CPT1A, FAH, LARS1, MPV17, NPC1, POLG, SUCLG1, and TWINK (1 each). The 12 children who were identified with biallelic variants were younger at presentation and more likely to die in comparison with those who did not: median age at presentation of 3 months and 30 months and survival rate 75% and 97%, respectively. CONCLUSIONS NGS was successful in identifying several specific etiologies of ALF. Variants in NBAS and mitochondrial DNA maintenance genes were the most common findings. In the future, a rapid sequencing NGS workflow could help in reaching a timely diagnosis and facilitate clinical decision making in children with ALF.
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Affiliation(s)
- Robert Hegarty
- Institute of Liver Studies, King's College Hospital, London, United Kingdom; Institute of Liver Studies, King's College London, London, United Kingdom; Pediatric Liver, GI and Nutrition Center and MowatLabs, King's College Hospital, London, United Kingdom.
| | - Philippa Gibson
- Institute of Liver Studies, King's College London, London, United Kingdom
| | - Melissa Sambrotta
- Institute of Liver Studies, King's College London, London, United Kingdom
| | - Sandra Strautnieks
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Pierre Foskett
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Sian Ellard
- Exeter Genetics Laboratory at Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Julia Baptista
- Exeter Genetics Laboratory at Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Suzanne Lillis
- Molecular Genetics Laboratory at Guy's Hospital, London, United Kingdom
| | - Sanjay Bansal
- Pediatric Liver, GI and Nutrition Center and MowatLabs, King's College Hospital, London, United Kingdom
| | - Roshni Vara
- Pediatric Liver, GI and Nutrition Center and MowatLabs, King's College Hospital, London, United Kingdom
| | - Anil Dhawan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom; Institute of Liver Studies, King's College London, London, United Kingdom; Pediatric Liver, GI and Nutrition Center and MowatLabs, King's College Hospital, London, United Kingdom
| | - Tassos Grammatikopoulos
- Institute of Liver Studies, King's College Hospital, London, United Kingdom; Institute of Liver Studies, King's College London, London, United Kingdom; Pediatric Liver, GI and Nutrition Center and MowatLabs, King's College Hospital, London, United Kingdom
| | - Richard J Thompson
- Institute of Liver Studies, King's College Hospital, London, United Kingdom; Institute of Liver Studies, King's College London, London, United Kingdom; Pediatric Liver, GI and Nutrition Center and MowatLabs, King's College Hospital, London, United Kingdom
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Kehar M, Ebel NH, Ng VL, Baquero JER, Leung DH, Slowik V, Ovchinsky N, Shah AA, Arnon R, Miloh T, Gupta N, Mohammad S, Kogan-Liberman D, Squires JE, Sanchez MC, Hildreth A, Book L, Chu C, Alrabadi L, Azzam R, Chepuri B, Elisofon S, Falik R, Gallagher L, Kader H, Mogul D, Mujawar Q, Namjoshi SS, Valentino PL, Vitola B, Waheed N, Zheng MH, Lobritto S, Martinez M. Severe Acute Respiratory Syndrome Coronavirus-2 Infection in Children With Liver Transplant and Native Liver Disease: An International Observational Registry Study. J Pediatr Gastroenterol Nutr 2021; 72:807-814. [PMID: 33605666 PMCID: PMC8183254 DOI: 10.1097/mpg.0000000000003077] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 02/06/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Increased mortality risk because of severe acute respiratory syndrome coronavirus-2 (SARS-CoV2) infection in adults with native liver disease (LD) and liver transplant (LT) is associated with advanced age and comorbid conditions. We aim to report outcomes for children with LD and LT enrolled in the NASPGHAN/SPLIT SARS-CoV2 registry. METHODS In this multicenter observational cohort study, we collected data from 91 patients <21 years (LD 44, LT 47) with laboratory-confirmed SARS-CoV2 infection between April 21 and September 17, 2020. RESULTS Patients with LD were more likely to require admission (70% vs 43% LT, P = 0.007) and pediatric intensive care unit (PICU) management (32% vs 4% LT, P = 0.001). Seven LD patients required mechanical ventilation (MV) and 2 patients died; no patients in the LT cohort died or required MV. Four LD patients presented in pediatric acute liver failure (PALF), 2 with concurrent multisystem inflammatory syndrome in children (MIS-C); all recovered without LT. Two LD patients had MIS-C alone and 1 patient died. Bivariable logistic-regression analysis found that patients with nonalcoholic fatty LD (NAFLD) (odds ratio [OR] 5.6, P = 0.02) and LD (OR 6.1, P = 0.01, vs LT) had higher odds of severe disease (PICU, vasopressor support, MV, renal replacement therapy or death). CONCLUSIONS Although not directly comparable, LT recipients had lower odds of severe SARS-CoV2 infection (vs LD), despite immunosuppression burden. NAFLD patients reported to the registry had higher odds of severe SARS-CoV2 disease. Future controlled studies are needed to evaluate effective treatments and further stratify LD and LT patients with SARS-CoV2 infection.
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Affiliation(s)
- Mohit Kehar
- Queen's University, Kingston
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Stanford University, Stanford, CA
| | | | - Vicky L. Ng
- Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | | | - Amit A. Shah
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Nitika Gupta
- Emory University School of Medicine, Atlanta, GA
| | | | | | | | | | | | - Linda Book
- Primary Children's Hospital, Salt Lake City, UT
| | | | | | | | | | | | - Rachel Falik
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Lisa Gallagher
- University of California, San Francisco, San Francisco, CA
| | - Howard Kader
- University of Maryland School of Medicine, Baltimore, MD
| | | | | | | | | | | | - Nadia Waheed
- Children's Hospital and the Institute of Child Health, Lahore, Pakistan
| | - Ming-Hua Zheng
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Di Giorgio A, Bartolini E, Calvo PL, Cananzi M, Cirillo F, Della Corte C, Dionisi-Vici C, Indolfi G, Iorio R, Maggiore G, Mandato C, Nebbia G, Nicastro E, Pinon M, Ranucci G, Sciveres M, Vajro P, D'Antiga L. Diagnostic Approach to Acute Liver Failure in Children: A Position Paper by the SIGENP Liver Disease Working Group. Dig Liver Dis 2021; 53:545-557. [PMID: 33775575 DOI: 10.1016/j.dld.2021.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023]
Abstract
Acute liver failure (ALF) is a clinical condition characterized by the abrupt onset of coagulopathy and biochemical evidence of hepatocellular injury, leading to rapid deterioration of liver cell function. In children, ALF has been characterized by raised transaminases, coagulopathy, and no known evidence of pre-existing chronic liver disease; unlike in adults, the presence of hepatic encephalopathy is not required to establish the diagnosis. Although rare, ALF has a high mortality rate without liver transplantation (LT). Etiology of ALF varies with age and geographical location, although it may remain indeterminate in a significant proportion of cases. However, identifying its etiology is crucial to undertake disease-specific management and evaluate indication to LT. In this position statement, the Liver Disease Working Group of the Italian Society of Gastroenterology, Hepatology and Nutrition (SIGENP) reviewed the most relevant studies on pediatric ALF to provide recommendations on etiology, clinical features and diagnostic work-up of neonates, infants and children presenting with ALF. Recommendations on medical management and transplant candidacy will be discussed in a following consensus conference.
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Affiliation(s)
- A Di Giorgio
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy.
| | - E Bartolini
- Department Neurofarba, University of Florence and Liver Unit, Meyer Children's University Hospital, Florence, Italy
| | - P L Calvo
- Paediatric Gastroenterology Unit, Regina Margherita Children's Hospital Azienda Ospedaliera-Universitaria Citta della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - M Cananzi
- Unit of Pediatric Gastroenterology and Hepatology, Dpt. of Women's and Children's Health, University Hospital of Padova, Italy
| | - F Cirillo
- Paediatric Department and Transplantation, Ismett, Palermo, Italy
| | - C Della Corte
- Paediatric Gastroenterology, Hepatology, Nutrition and Liver Transplantation, IRCCS Bambino Gesù Paediatric Hospital, Rome, Italy
| | - C Dionisi-Vici
- Division of Metabolic Diseases, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - G Indolfi
- Department Neurofarba, University of Florence and Liver Unit, Meyer Children's University Hospital, Florence, Italy
| | - R Iorio
- Paediatric Liver Unit, Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
| | - G Maggiore
- Paediatric Gastroenterology, Hepatology, Nutrition and Liver Transplantation, IRCCS Bambino Gesù Paediatric Hospital, Rome, Italy
| | - C Mandato
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - G Nebbia
- Pediatric Liver Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - E Nicastro
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy
| | - M Pinon
- Paediatric Gastroenterology Unit, Regina Margherita Children's Hospital Azienda Ospedaliera-Universitaria Citta della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - G Ranucci
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - M Sciveres
- Paediatric Department and Transplantation, Ismett, Palermo, Italy
| | - P Vajro
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" Section of Pediatrics, University of Salerno, Baronissi (Salerno), Italy
| | - L D'Antiga
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy
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Grama A, Aldea CO, Burac L, Delean D, Bulata B, Sirbe C, Duca E, Boghitoiu D, Coroleuca A, Pop TL. Etiology and Outcome of Acute Liver Failure in Children-The Experience of a Single Tertiary Care Hospital from Romania. CHILDREN (BASEL, SWITZERLAND) 2020; 7:E282. [PMID: 33317098 PMCID: PMC7763257 DOI: 10.3390/children7120282] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/04/2020] [Accepted: 12/06/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Acute liver failure (ALF) is a rare disease, associated with high mortality, despite optimal medical therapy without emergency liver transplantation. Knowing the possible cause of ALF plays a vital role in the management, as the child could benefit from effective specific therapies in emergencies. METHODS We have analyzed the etiology and outcome of ALF in children followed-up in a tertiary care hospital between January 2012-December 2018. The patients were grouped into different age categories: neonates (0-1 month), infants (1-12 months), children (1-14 years), and teenagers (14-18 years). RESULTS 97 children (46 males, 47.42%, the mean age of 7.66 ± 8.18 years) were admitted with ALF. The most important causes of ALF were in neonates and infants, infections (72.72%), and metabolic disorders (43.47%), in children and adolescents were the toxic causes (60% and 79.41%). The mortality rate was 31.95% (31 patients), mainly in ALF due to infections or metabolic disorders. CONCLUSIONS In neonates and infants, the main causes of ALF were infections and metabolic diseases, while in older children and teenagers, were toxin-induced liver injuries. The mortality among neonates and infants was significantly higher than in other ages. Early recognition and immediate therapeutic intervention could improve the outcome of these patients.
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Affiliation(s)
- Alina Grama
- 2nd Pediatric Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400012 Cluj-Napoca, Romania; (A.G.); (L.B.); (C.S.); (E.D.)
- Center of Expertise in Pediatric Liver Rare Disorders, 2nd Pediatric Clinic, Emergency Clinic Hospital for Children, 400177 Cluj-Napoca, Romania
- University of Medicine and Pharmacy Carol Davila, 050474 Bucharest, Romania; (D.B.); (A.C.)
| | - Cornel Olimpiu Aldea
- Pediatric Nephrology, Dialysis and Toxicology Clinic, Emergency Clinic Hospital for Children, 400177 Cluj-Napoca, Romania; (C.O.A.); (D.D.); (B.B.)
| | - Lucia Burac
- 2nd Pediatric Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400012 Cluj-Napoca, Romania; (A.G.); (L.B.); (C.S.); (E.D.)
- Center of Expertise in Pediatric Liver Rare Disorders, 2nd Pediatric Clinic, Emergency Clinic Hospital for Children, 400177 Cluj-Napoca, Romania
| | - Dan Delean
- Pediatric Nephrology, Dialysis and Toxicology Clinic, Emergency Clinic Hospital for Children, 400177 Cluj-Napoca, Romania; (C.O.A.); (D.D.); (B.B.)
| | - Bogdan Bulata
- Pediatric Nephrology, Dialysis and Toxicology Clinic, Emergency Clinic Hospital for Children, 400177 Cluj-Napoca, Romania; (C.O.A.); (D.D.); (B.B.)
| | - Claudia Sirbe
- 2nd Pediatric Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400012 Cluj-Napoca, Romania; (A.G.); (L.B.); (C.S.); (E.D.)
| | - Emanuela Duca
- 2nd Pediatric Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400012 Cluj-Napoca, Romania; (A.G.); (L.B.); (C.S.); (E.D.)
| | - Dora Boghitoiu
- University of Medicine and Pharmacy Carol Davila, 050474 Bucharest, Romania; (D.B.); (A.C.)
| | - Alexandra Coroleuca
- University of Medicine and Pharmacy Carol Davila, 050474 Bucharest, Romania; (D.B.); (A.C.)
| | - Tudor Lucian Pop
- 2nd Pediatric Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400012 Cluj-Napoca, Romania; (A.G.); (L.B.); (C.S.); (E.D.)
- Center of Expertise in Pediatric Liver Rare Disorders, 2nd Pediatric Clinic, Emergency Clinic Hospital for Children, 400177 Cluj-Napoca, Romania
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Activated CD8 T-cell Hepatitis in Children With Indeterminate Acute Liver Failure: Results From a Multicenter Cohort. J Pediatr Gastroenterol Nutr 2020; 71:713-719. [PMID: 32796431 DOI: 10.1097/mpg.0000000000002893] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In many pediatric acute liver failure (PALF) cases, a diagnosis is not identified, and the etiology is indeterminate (IND-PALF). Our pilot study found dense CD8 T-cell infiltrates and increased T-cell clonality in liver specimens from IND-PALF patients. We aimed to validate these findings in a multicenter cohort with investigators blinded to diagnosis. METHODS PALF Study Group registry subjects with IND-PALF (n = 37) and known diagnoses (DX-PALF) (n = 18), ages 1 to 17 years, with archived liver tissue were included. Liver tissue slides were stained for T cells (CD8 and CD4), B cells (CD20), macrophages (CD163), perforin, and tissue resident-memory T cells (Trm, CD103), and scored as minimal, moderate, or dense. Lymphocytes were isolated from frozen liver tissue for T-cell receptor beta (TCRβ) sequencing. RESULTS Dense hepatic CD8 staining was found in significantly more IND-PALF (n = 29, 78%) compared with DX-PALF subjects (n = 5, 28%) (P = 0.001). IND-PALF subjects were more likely to have dense or moderate perforin (88% vs 50%, P = 0.03) and CD103 (82% vs 40%, P = 0.02) staining compared with DX-PALF subjects. TCRβ sequencing of 15 IND-PALF cases demonstrated increased clonal overlap compared with 6 DX-PALF cases (P = 0.002). CONCLUSIONS Dense infiltration of effector Trm CD8 T cells characterizes liver tissue from IND-PALF subjects. Increased clonality suggests the T-cell expansion is antigen(s)-driven as opposed to a nonspecific inflammatory response. These findings support CD8 staining as a new biomarker of the activated CD8 T-cell PALF phenotype. Future studies are needed to characterize potential antigens, host risk factors, and inflammatory pathways with the goal of developing targeted therapies.
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Pediatric chronic liver failure-sequential organ failure assessment score and outcome of acute liver failure in children. Clin Exp Hepatol 2020; 6:228-234. [PMID: 33145429 PMCID: PMC7592098 DOI: 10.5114/ceh.2020.99129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 05/16/2020] [Indexed: 12/28/2022] Open
Abstract
Aim of the study Liver transplantation remains the only definitive treatment for children with acute liver failure proven to have irreversible liver injury. Many prognostic models have been used for outcome prediction in pediatric acute liver failure to select patients in a real need of liver transplantation, but unfortunately all have shown inconsistent reproducibility and prognostic accuracy. The aim of this study was to evaluate the pediatric chronic liver failure sequential organ failure assessment (pCLIF-SOFA) score as a predictor of pediatric acute liver failure outcome. Material and methods Clinical and laboratory data of 41 children with acute liver failure admitted to the National Liver Institute – Menoufia University were collected retrospectively and used for calculation of both pCLIF-SOFA and Pediatric End-Stage Liver Disease (PELD)/Model for End-Stage Liver Disease (MELD) scores on the day of admission, then statistical analysis was performed to identify the ability of these scores to predict the outcome. Results According to the outcome, children enrolled in this study were allocated to survived (n = 16) and died (n = 25) groups, which were age and sex matched. The non-survival group had significantly higher values of both pCLIF-SOFA score (11 [7-13]) and PELD/MELD score (36 [18-42]) than those of the survival group (8 [7-11], 27.5 [15-45]; p < 0.001, p = 0.004) respectively. Both pCLIF-SOFA and PELD/MELD scores at cut-off values > 8 and > 30 respectively on admission could predict death in children with acute liver failure (ALF) with high sensitivity, but with higher specificity, positive and negative predictive values for pCLIF-SOFA. Conclusions pCLIF-SOFA is a good predictor of death in pediatric acute liver failure.
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Verna EC, Serper M, Chu J, Corey K, Fix OK, Hoyt K, Page KA, Loomba R, Li M, Everson GT, Fried MW, Garcia‐Tsao G, Terrault N, Lok AS, Chung RT, Reddy KR. Clinical Research in Hepatology in the COVID-19 Pandemic and Post-Pandemic Era: Challenges and the Need for Innovation. Hepatology 2020; 72:1819-1837. [PMID: 32740969 PMCID: PMC7435542 DOI: 10.1002/hep.31491] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 12/14/2022]
Abstract
The severe acute respiratory syndrome coronavirus 2 pandemic has drastically altered all facets of clinical care and research. Clinical research in hepatology has had a rich tradition in several domains, including the discovery and therapeutic development for diseases such as hepatitis B and C and studying the natural history of many forms of chronic liver disease. National Institutes of Health, foundation, and industry funding have provided important opportunities to advance the academic careers of young investigators while they strived to make contributions to the field. Instantaneously, however, all nonessential research activities were halted when the pandemic started, forcing those involved in clinical research to rethink their research strategy, including a shift to coronavirus disease 2019 research while endeavoring to maintain their preexisting agenda. Strategies to maintain the integrity of ongoing studies, including patient follow-up, safety assessments, and continuation of investigational products, have included a shift to telemedicine, remote safety laboratory monitoring, and shipping of investigational products to study subjects. As a revamp of research is being planned, unique issues that face the research community include maintenance of infrastructure, funding, completion of studies in the predetermined time frame, and the need to reprogram career path timelines. Real-world databases, biomarker and long-term follow up studies, and research involving special groups (children, the homeless, and other marginalized populations) are likely to face unique challenges. The implementation of telemedicine has been dramatically accelerated and will serve as a backbone for the future of clinical research. As we move forward, innovation in clinical trial design will be essential for conducting optimized clinical research.
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Affiliation(s)
- Elizabeth C. Verna
- Center for Liver Disease and TransplantationColumbia University Irving Medical CenterNew YorkNY
| | - Marina Serper
- Division of Gastroenterology and HepatologyUniversity of PennsylvaniaPhiladelphiaPA
| | - Jaime Chu
- Division of Pediatric HepatologyMt. Sinai School of MedicineNew YorkNY
| | | | - Oren K. Fix
- Organ Transplant and Liver CenterSwedish Medical CenterSeattleWA
| | | | - Kimberly A. Page
- Division of Epidemiology, Biostatistics and Preventive Medicine, Department of Internal MedicineUniversity of New Mexico School of MedicineAlbuquerqueNM
| | - Rohit Loomba
- Division of GastroenterologyUC San Diego School of MedicineSan DiegoCA
| | - Ming Li
- Keck School of Medicine of USCLos AngelesCA
| | - Gregory T. Everson
- Division of Gastroenterology and Hepatology, Department of Internal MedicineUniversity of Colorado Denver School of MedicineAuroraCO
- HepQuant LLCGreenwood VillageCO
| | - Michael W. Fried
- Division of Gastroenterology and HepatologyUniversity of North Carolina School of MedicineChapel HillNC
| | | | | | - Anna S. Lok
- Division of GastroenterologyUniversity of Michigan Medical SchoolAnn ArborMI
| | | | - K. Rajender Reddy
- Division of Gastroenterology and HepatologyUniversity of PennsylvaniaPhiladelphiaPA
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Yang CH, Sahoo MK, Fitzpatrick M, Lau AH, Pinsky BA, Martinez OM. Evaluating for Human Herpesvirus 6 in the Liver Explants of Children With Liver Failure of Unknown Etiology. J Infect Dis 2020; 220:361-369. [PMID: 30418598 DOI: 10.1093/infdis/jiy644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/05/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Liver failure of unknown etiology (LFUE) has a transplant-free survival rate <25%. Human herpesvirus 6 (HHV-6) may be associated with LFUE, but studies are limited by small sample size. METHODS We identified all children who underwent liver transplant for LFUE at a single quaternary children's hospital; 51/65 cases could be age matched with controls (children who underwent liver transplant for metabolic liver disease). Quantitative polymerase chain reaction for HHV-6 was performed on DNA from formalin-fixed paraffin-embedded liver explant tissue. RESULTS HHV-6 was detected in 34/51 cases (66.7%) and 19/51 controls (37.3%) (P = .005). Average HHV-6 viral load was 213207 copies/106 cells in positive cases (range: 7293-1102030) and 38115 copies/106 cells in positive controls (range: 1382-122375) (P = .0008). HHV-6 was present significantly more often in cases compared to controls in patients younger than 6 years. In particular, in patients younger than 3 years, HHV-6 was present in 13/27 cases (48.1%) and 2/27 controls (7.4%) (P = .0009). CONCLUSIONS HHV-6 was detected in liver explants significantly more often and in higher quantities in children transplanted for LFUE compared to controls, suggesting HHV-6 should be evaluated in young children who present with LFUE.
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Affiliation(s)
- Christine H Yang
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | | | | | | | - Benjamin A Pinsky
- Department of Pathology.,Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, California
| | - Olivia M Martinez
- Department of Surgery, Division of Abdominal Transplantation and Stanford Immunology, Stanford University Medical Center, California
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Prencipe G, Bracaglia C, Caiello I, Pascarella A, Francalanci P, Pardeo M, Meneghel A, Martini G, Rossi MN, Insalaco A, Marucci G, Nobili V, Spada M, Zulian F, De Benedetti F. The interferon-gamma pathway is selectively up-regulated in the liver of patients with secondary hemophagocytic lymphohistiocytosis. PLoS One 2019; 14:e0226043. [PMID: 31846457 PMCID: PMC6917341 DOI: 10.1371/journal.pone.0226043] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 11/19/2019] [Indexed: 12/24/2022] Open
Abstract
Aim of this study was to investigate the activation of the IFNγ pathway in the affected liver and in the blood of patients with secondary hemophagocytic lymphohistiocytosis (sHLH). To this purpose, the mRNA expression levels of IFNG and IFNγ-inducible genes as well as Tyrosine (701)-phosphorylated signal transducer and activator of transcription 1 (STAT1) protein levels were evaluated in the liver and in peripheral blood mononuclear cells (PBMCs) of three patients with sHLH with predominant liver involvement. The mRNA expression levels of IFNG and IFNγ-inducible genes were markedly higher in patient livers compared to control livers and to one disease control liver. Conversely, slight differences in the expression levels of Type I IFN-inducible genes and other classical inflammatory cytokine genes were found. Further supporting the activation of the IFNγ pathway, higher protein levels of phosphorylated and total STAT1 were detected in patient livers compared to control livers. When the expression of the same genes analysed in liver tissues was evaluated in PBMCs collected from 2 out of 3 patients before the liver biopsy, we found that mRNA levels of IFNγ-inducible genes were markedly increased. Accordingly, high circulating levels of IFNγ-inducible CXCL9 were observed in patients. Altogether, these data demonstrate the selective and marked up-regulation of the IFNγ pathway in the liver tissue and blood of patients with active sHLH. Finally, we show that measurement of circulating CXCL9 levels and evaluation of IFNγ-inducible gene expression levels in PBMCs may represent a new valid tool to better identify patients with suspected HLH with predominant liver involvement.
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Affiliation(s)
- Giusi Prencipe
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- * E-mail:
| | - Claudia Bracaglia
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Ivan Caiello
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Antonia Pascarella
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Paola Francalanci
- Department of Pathology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Manuela Pardeo
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | | | - Giorgia Martini
- Department of Woman and Child Health, University of Padua, Padua, Italy
| | - Marianna N. Rossi
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Antonella Insalaco
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Giulia Marucci
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Valerio Nobili
- Hepatology Gastroenterology and Nutrition Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesco Zulian
- Department of Woman and Child Health, University of Padua, Padua, Italy
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HMGB1 is a Central Driver of Dynamic Pro-inflammatory Networks in Pediatric Acute Liver Failure induced by Acetaminophen. Sci Rep 2019; 9:5971. [PMID: 30979951 PMCID: PMC6461628 DOI: 10.1038/s41598-019-42564-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/27/2019] [Indexed: 12/12/2022] Open
Abstract
Acetaminophen (APAP) overdose (APAPo) is predominant in the NIH Pediatric Acute Liver Failure (PALF) Study. We assayed multiple inflammatory mediators in serial serum samples from 13 PALF survivors with APAPo + N-acetylcysteine (NAC, the frontline therapy for APAPo), 8 non-APAPo + NAC, 40 non-APAPo non-NAC, and 12 non-survivors. High Mobility Group Box 1 (HMGB1) was a dominant mediator in dynamic inflammation networks in all sub-groups, associated with a threshold network complexity event at d1–2 following enrollment that was exceeded in non-survivors vs. survivors. We thus hypothesized that differential HMGB1 network connectivity after day 2 is related to the putative threshold event in non-survivors. DyNA showed that HMGB1 is most connected in non-survivors on day 2–3, while no connections were observed in APAPo + NAC and non-APAPo + NAC survivors. Inflammatory dynamic networks, and in particular HMGB1 connectivity, were associated with the use of NAC in the context of APAPo. To recapitulate hepatocyte (HC) damage in vitro, primary C57BL/6 HC and HC-specific HMGB1-null HC were treated with APAP + NAC. Network phenotypes of survivors were recapitulated in C57BL/6 mouse HC and were greatly altered in HMGB1-null HC. HC HMGB1 may thus coordinate a pro-inflammatory program in PALF non-survivors (which is antagonized by NAC), while driving an anti-inflammatory/repair program in survivors.
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Squires JE, Rudnick DA, Hardison RM, Horslen S, Ng VL, Alonso EM, Belle SH, Squires RH. Liver Transplant Listing in Pediatric Acute Liver Failure: Practices and Participant Characteristics. Hepatology 2018; 68:2338-2347. [PMID: 30070372 PMCID: PMC6275095 DOI: 10.1002/hep.30116] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 05/24/2018] [Indexed: 12/19/2022]
Abstract
Liver transplant (LT) decisions in pediatric acute liver failure (PALF) are complex. Three phases of the PALF registry, containing data on 1,144 participants over 15 years, were interrogated to characterize clinical features associated with listing status. A decrease in the cumulative incidence of listing (P < 0.005) and receiving (P < 0.05) LT occurred without an increase in the cumulative incidence of death (P = 0.67). Time to listing was constant and early (1 day; quartiles 1-3 = 0-2; P = 0.88). The most frequent reasons for not listing were "not sick enough" and "medically unsuitable." Participants listed for LT were more likely male, with coma grade scores >0; had higher international normalized ratio, bilirubin, lactate, and venous ammonia; and had lower peripheral lymphocytes and transaminase levels compared to those deemed "not sick enough." Participants listed versus those deemed "medically unsuitable" were older; had higher serum aminotransferase levels, bilirubin, platelets, and albumin; and had lower lactate, venous ammonia, and lymphocyte count. An indeterminate diagnosis was more prevalent in listed participants. Ventilator (23.8%) and vasopressor (9.2%) support occurred in a significant portion of listed participants but less frequently than in those who were not "medically suitable." Removal from the LT list was a rare event. Conclusion: The cumulative incidence of listing for and receiving LT decreased throughout the PALF study without an increase in the cumulative incidence of death. While all participants fulfilled entry criteria for PALF, significant differences were noted between participants listed for LT and those deemed "not sick enough" as well as those who were "medically unsuitable." Having an indeterminate diagnosis and a requirement for cardiopulmonary support appeared to influence decisions toward listing; optimizing listing decisions in PALF may reduce the frequency of LT without increasing the frequency of death.
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Affiliation(s)
- James E Squires
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - David A Rudnick
- Pediatric Hepatology Departments of Pediatrics and Developmental Biology, Washington University School of Medicine, St. Louis, MO, United States
| | - Regina M Hardison
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Simon Horslen
- Pediatric Hepatology, Seattle Children’s Hospital, Seattle, WA, United States
| | - Vicky L Ng
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, ON, Canada
| | - Estella M Alonso
- Pediatric Hepatology, Ann and Robert H Lurie Children’s Hospital, Chicago, IL, United States
| | - Steven H Belle
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Robert H Squires
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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Zhang LN, Guo W, Zhu JH, Guo Y. Successful rescue of acute liver failure and hemophagocytic lymphohistiocytosis following varicella infection: A case report and review of literature. World J Clin Cases 2018; 6:659-665. [PMID: 30430121 PMCID: PMC6232574 DOI: 10.12998/wjcc.v6.i13.659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/10/2018] [Accepted: 10/09/2018] [Indexed: 02/05/2023] Open
Abstract
Herein we report a case of acute liver failure (ALF) and hemophagocytic lymphohistiocytosis (HLH) induced by varicella infection, successfully rescued by a combination therapy of acyclovir, supportive care, and immunosuppression with dexamethasone and etoposide. A previously healthy 16-year-old boy presented with generalized rash, fever, severe abdominal pain, and abnormal liver function within 4 d. Chickenpox was suspected, and acyclovir and intravenous immunoglobulin were started on admission. However, the patient’s condition deteriorated overnight with soaring transaminases, severe coagulopathy and encephalopathy. On the fourth day of admission, pancytopenia emerged, accompanied by hypofibrinogenemia and hyperferritinemia. The patient was diagnosed with ALF. He also met the diagnostic criteria of HLH according to the HLH-2004 guideline. Polymerase chain reaction (PCR) amplifications of varicella-zoster virus (VZV) were positive, confirming that VZV was a causative trigger for ALF and HLH. In view of the devastating immune activation in HLH, immunosuppression therapy with dexamethasone and etoposide was administered, in addition to high dose acyclovir. The patient’s symptoms improved dramatically and he finally made a full recovery. To our knowledge, this is only the second report of a successful rescue of ALF associated with HLH, without resorting to liver transplantation. The first case was reported in a neonate infected by herpes simplex virus-1. However, survival data in older children and adults are lacking, most of whom died or underwent liver transplantation. Our report emphasizes the clinical vigilance for the possible presence of HLH, and the necessity of extensive investigation for underlying etiologies in patients presenting with indeterminate ALF. Early initiation of specific therapy targeting the underlying etiology, and watchful immunosuppression such as dexamethasone and etoposide, together with supportive therapy, are of crucial importance in this life-threatening disorder.
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Affiliation(s)
- Li-Na Zhang
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing 100044, China
| | - Wei Guo
- Department of Emergency, Peking University People’s Hospital, Beijing 100044, China
| | - Ji-Hong Zhu
- Department of Emergency, Peking University People’s Hospital, Beijing 100044, China
| | - Yang Guo
- Department of Emergency, Peking University People’s Hospital, Beijing 100044, China
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Abstract
Pediatric acute liver failure (PALF) is a dynamic, life-threatening condition of disparate etiology. Management of PALF is dependent on intensive collaborative clinical care and support. Proper recognition and treatment of common complications of liver failure are critical to optimizing outcomes. In parallel, investigations to identify underlying cause and the implementation of timely, appropriate treatment can be life-saving. Predicting patient outcome in the era of liver transplantation has been unfulfilling and better predictive models must be developed for proper stewardship of the limited resource of organ availability.
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Affiliation(s)
- James E Squires
- Department of Pediatric Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Patrick McKiernan
- Department of Pediatric Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - Robert H Squires
- Department of Pediatric Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
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