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Verkade HJ, Felzen A, Keitel V, Thompson R, Gonzales E, Strnad P, Kamath B, van Mil S. EASL Clinical Practice Guidelines on genetic cholestatic liver diseases. J Hepatol 2024; 81:303-325. [PMID: 38851996 DOI: 10.1016/j.jhep.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/05/2024] [Indexed: 06/10/2024]
Abstract
Genetic cholestatic liver diseases are caused by (often rare) mutations in a multitude of different genes. While these diseases differ in pathobiology, clinical presentation and prognosis, they do have several commonalities due to their cholestatic nature. These Clinical Practice Guidelines (CPGs) offer a general approach to genetic testing and management of cholestatic pruritus, while exploring diagnostic and treatment approaches for a subset of genetic cholestatic liver diseases in depth. An expert panel appointed by the European Association for the Study of the Liver has created recommendations regarding diagnosis and treatment, based on the best evidence currently available in the fields of paediatric and adult hepatology, as well as genetics. The management of these diseases generally takes place in a tertiary referral centre, in order to provide up-to-date approaches and expertise. These CPGs are intended to support hepatologists (for paediatric and adult patients), residents and other healthcare professionals involved in the management of these patients with concrete recommendations based on currently available evidence or, if not available, on expert opinion.
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Heinz N, Vittorio J. Treatment of Cholestasis in Infants and Young Children. Curr Gastroenterol Rep 2023; 25:344-354. [PMID: 37651067 DOI: 10.1007/s11894-023-00891-8] [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] [Accepted: 08/17/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE OF REVIEW Cholestasis is characterized by a conjugated hyperbilirubinemia secondary to impaired bile synthesis, transport, or excretion from the liver. It is always pathologic and can be indicative of an underlying hepatobiliary, genetic, or metabolic disorder, several of which require timely diagnosis to ensure proper management and optimal outcomes. This review provides an overview of the evaluation of cholestasis with a focus on current and emerging treatment strategies. RECENT FINDINGS Increased accessibility of next generation sequencing (NGS) allows for utilization of genetic testing early in the diagnostic process. This may alter the clinical algorithm for diagnosis of cholestatic disorders. An enhanced understanding of the underlying pathophysiology may help guide future development of targeted therapies, such as ileal bile acid transporter (IBAT) inhibitors. These were recently approved for treatment of cholestatic pruritus in patients with Alagille syndrome and Progressive Familial Intrahepatic Cholestasis. Current management of cholestasis is aimed at the biochemical consequences of impaired bile flow, including malnutrition, pruritus, and progressive fibrosis. NGS has led to an enhanced understanding of biliary pathology and may guide development of future treatment modalities based on specific gene mutations. Rapid discernment of the underlying etiology is essential as new treatment modalities emerge.
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Affiliation(s)
- Nicole Heinz
- New York University (NYU) Transplant Institute, NYU Langone Health, 160 East 32nd Street, Suite L3 Medical Level, New York, NY, USA
| | - Jennifer Vittorio
- New York University (NYU) Transplant Institute, NYU Langone Health, 160 East 32nd Street, Suite L3 Medical Level, New York, NY, USA.
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Ruiz M, Lacaille F, Schrader C, Pons M, Socha P, Krag A, Sturm E, Bouchecareilh M, Strnad P. Pediatric and Adult Liver Disease in Alpha-1 Antitrypsin Deficiency. Semin Liver Dis 2023; 43:258-266. [PMID: 37402396 DOI: 10.1055/a-2122-7674] [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] [Indexed: 07/06/2023]
Abstract
Alpha-1 antitrypsin deficiency (AATD) arises due to inherited variants in SERPINA1, the AAT gene that impairs the production or secretion of this hepatocellular protein and leads to a gain-of-function liver proteotoxicity. Homozygous Pi*Z pathogenic variant (Pi*ZZ genotype) is the leading cause of severe AATD. It manifests in 2 to 10% of carriers as neonatal cholestasis and 20 to 35% of adults as significant liver fibrosis. Both children and adults may develop an end-stage liver disease requiring liver transplantation. Heterozygous Pi*Z pathogenic variant (Pi*MZ genotype) constitutes an established disease modifier. Our review summarizes the natural history and management of subjects with both pediatric and adult AATD-associated liver disease. Current findings from a phase 2 clinical trial indicate that RNA silencing may constitute a viable therapeutic approach for adult AATD. In conclusion, AATD is an increasingly appreciated pediatric and adult liver disorder that is becoming an attractive target for modern pharmacologic strategies.
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Affiliation(s)
- Mathias Ruiz
- Hépatologie, Gastroentérologie et Nutrition Pédiatriques, Hôpital Femme Mère Enfant, Hospices civils de Lyon, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Lyon, France
| | - Florence Lacaille
- Service de Gastroentérologie-Nutrition Pédiatriques et Unité d'Hépatologie Pédiatrique Hôpital Universitaire Necker-Enfants Malades, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Paris, France
| | - Christina Schrader
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
| | - Monica Pons
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autonoma de Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Piotr Socha
- The Children's Memorial Health Institute, Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, Al. Dzieci Polskich, Warszawa, Poland
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Ekkehard Sturm
- Pediatric Gastroenterology and Hepatology, University Children's Hospital Tübingen, Member Center of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Tübingen, Germany
| | | | - Pavel Strnad
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
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Characteristics of infections and their risk factors in children with biliary atresia. Clin Res Hepatol Gastroenterol 2023; 47:102109. [PMID: 36882124 DOI: 10.1016/j.clinre.2023.102109] [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: 09/09/2022] [Revised: 01/31/2023] [Accepted: 02/27/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Children with biliary atresia (BA) may experience various infections (e.g., cholangitis, bacteremia, and viral respiratory infections (VRI)) throughout their disease course. This study aimed to identify and describe these infections and their risk factors for development in children with BA. METHODS This retrospective observational study identified infections in children with BA using predefined criteria, including VRI, bacteremia with and without central line (CL), bacterial peritonitis, positive stool pathogens, urinary tract infections, and cholangitis. Infections were identified until liver transplant, death or last follow-up with native liver. Infection-free survival was estimated by Kaplan-Meier analysis. Logistic regression was used to estimate odds of infection per clinical characteristics. Cluster analysis was performed to identify patterns of infection development. RESULTS 48 of 65 (73.8%) children had ≥1 infection during their disease course (mean length of follow up: 40.2 months). Cholangitis (n = 30) and VRI (n = 21) were most common. Nearly half (45%) of all infections developed within 3-months of Kasai hepatoportoenterostomy. Kasai performed ≥45 days of life was associated with 3.5-fold increased risk of any infection (95% CI 1.2-11.4). Risk of VRI was inversely related to platelet count at 1-month post-Kasai (OR 0.5, 0.19-0.99). Cluster analysis of infectious patterns identified three unique cohorts of patients based on their infection history: no/few infections (n = 18), mostly cholangitis (n = 20) or mixed infections (n = 27). CONCLUSION Variability of infection risk exists amongst children with BA. Age at Kasai and platelet count are risk factors for future infections, suggesting that patients with more severe disease are at greater risk. Cirrhosis associated immune deficiency may exist in chronic pediatric liver disease and should be the subject of future investigations in order to optimize outcomes.
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Leung DH, Devaraj S, Goodrich NP, Chen X, Rajapakshe D, Ye W, Andreev V, Minard CG, Guffey D, Molleston JP, Bass LM, Karpen SJ, Kamath BM, Wang KS, Sundaram SS, Rosenthal P, McKiernan P, Loomes KM, Jensen MK, Horslen SP, Bezerra JA, Magee JC, Merion RM, Sokol RJ, Shneider BL, Alonso E, Bass L, Kelly S, Riordan M, Melin-Aldana H, Bezerra J, Bove K, Heubi J, Miethke A, Tiao G, Denlinger J, Chapman E, Sokol R, Feldman A, Mack C, Narkewicz M, Suchy F, Sundaram SS, Van Hove J, Garcia B, Kauma M, Kocher K, Steinbeiss M, Lovell M, Loomes KM, Piccoli D, Rand E, Russo P, Spinner N, Erlichman J, Stalford S, Pakstis D, King S, Squires R, Sindhi R, Venkat V, Bukauskas K, McKiernan P, Haberstroh L, Squires J, Rosenthal P, Bull L, Curry J, Langlois C, Kim G, Teckman J, Kociela V, Nagy R, Patel S, Cerkoski J, Molleston JP, Bozic M, Subbarao G, Klipsch A, Sawyers C, Cummings O, Horslen SP, Murray K, Hsu E, Cooper K, Young M, Finn L, Kamath BM, Ng V, Quammie C, Putra J, Sharma D, Parmar A, Guthery S, Jensen K, Rutherford A, Lowichik A, Book L, Meyers R, Hall T, Wang KS, Michail S, Thomas D, Goodhue C, Kohli R, Wang L, Soufi N, Thomas D, Karpen S, Gupta N, Romero R, Vos MB, Tory R, Berauer JP, Abramowsky C, McFall J, Shneider BL, Harpavat S, Hertel P, Leung D, Tessier M, Schady D, Cavallo L, Olvera D, Banks C, Tsai C, Thompson R, Doo E, Hoofnagle J, Sherker A, Torrance R, Hall S, Magee J, Merion R, Spino C, Ye W. Serum biomarkers correlated with liver stiffness assessed in a multicenter study of pediatric cholestatic liver disease. Hepatology 2023; 77:530-545. [PMID: 36069569 PMCID: PMC10151059 DOI: 10.1002/hep.32777] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/26/2022] [Accepted: 08/03/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIMS Detailed investigation of the biological pathways leading to hepatic fibrosis and identification of liver fibrosis biomarkers may facilitate early interventions for pediatric cholestasis. APPROACH AND RESULTS A targeted enzyme-linked immunosorbent assay-based panel of nine biomarkers (lysyl oxidase, tissue inhibitor matrix metalloproteinase (MMP) 1, connective tissue growth factor [CTGF], IL-8, endoglin, periostin, Mac-2-binding protein, MMP-3, and MMP-7) was examined in children with biliary atresia (BA; n = 187), alpha-1 antitrypsin deficiency (A1AT; n = 78), and Alagille syndrome (ALGS; n = 65) and correlated with liver stiffness (LSM) and biochemical measures of liver disease. Median age and LSM were 9 years and 9.5 kPa. After adjusting for covariates, there were positive correlations among LSM and endoglin ( p = 0.04) and IL-8 ( p < 0.001) and MMP-7 ( p < 0.001) in participants with BA. The best prediction model for LSM in BA using clinical and lab measurements had an R2 = 0.437; adding IL-8 and MMP-7 improved R2 to 0.523 and 0.526 (both p < 0.0001). In participants with A1AT, CTGF and LSM were negatively correlated ( p = 0.004); adding CTGF to an LSM prediction model improved R2 from 0.524 to 0.577 ( p = 0.0033). Biomarkers did not correlate with LSM in ALGS. A significant number of biomarker/lab correlations were found in participants with BA but not those with A1AT or ALGS. CONCLUSIONS Endoglin, IL-8, and MMP-7 significantly correlate with increased LSM in children with BA, whereas CTGF inversely correlates with LSM in participants with A1AT; these biomarkers appear to enhance prediction of LSM beyond clinical tests. Future disease-specific investigations of change in these biomarkers over time and as predictors of clinical outcomes will be important.
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Affiliation(s)
- Daniel H Leung
- Division of Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Department of Pediatrics , Baylor College of Medicine , Houston , Texas , USA
| | - Sridevi Devaraj
- Department of Pathology and Immunology , Texas Children's Hospital, Baylor College of Medicine , Houston , Texas , USA
| | - Nathan P Goodrich
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Xinpu Chen
- Department of Pathology and Immunology , Texas Children's Hospital, Baylor College of Medicine , Houston , Texas , USA
| | - Deepthi Rajapakshe
- Department of Pathology and Immunology , Texas Children's Hospital, Baylor College of Medicine , Houston , Texas , USA
| | - Wen Ye
- Department of Biostatistics , University of Michigan , Ann Arbor , Michigan , USA
| | - Victor Andreev
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Charles G Minard
- Institute for Clinical and Translational Research , Baylor College of Medicine , Houston , Texas , USA
| | - Danielle Guffey
- Institute for Clinical and Translational Research , Baylor College of Medicine , Houston , Texas , USA
| | - Jean P Molleston
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics , Riley Hospital for Children , Indiana University , Indianapolis , Indiana , USA
| | - Lee M Bass
- Department of Pediatrics , Ann & Robert H. Lurie Children's Hospital of Chicago , Northwestern University Feinberg School of Medicine , Chicago , Illinois , USA
| | - Saul J Karpen
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, Department of Pediatrics , Emory University School of Medicine , Atlanta , Georgia , USA
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition , Hospital for Sick Children, University of Toronto , Toronto , Ontario , Canada
| | - Kasper S Wang
- Department of Pediatric Surgery , Children's Hospital Los Angeles , Los Angeles , California , USA
| | - Shikha S Sundaram
- Pediatric Gastroenterology, Hepatology and Nutrition , Children's Hospital Colorado, University of Colorado School of Medicine , Aurora , Colorado , USA
| | - Philip Rosenthal
- Department of Pediatrics , University of California, San Francisco , San Francisco , California , USA
| | - Patrick McKiernan
- Pediatric Gastroenterology, Hepatology and Nutrition , Children's Hospital of Pittsburgh , Pittsburg , Pennsylvania , USA
| | - Kathleen M Loomes
- Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania , Philadelphia , Pennsylvania , USA
| | - M Kyle Jensen
- Pediatric Gastroenterology, Hepatology and Nutrition , University of Utah School of Medicine , Salt Lake City , Utah , USA
| | - Simon P Horslen
- Pediatric Gastroenterology, Hepatology and Nutrition , Seattle Children's Hospital, University of Washington School of Medicine , Seattle , Washington , USA
| | - Jorge A Bezerra
- Pediatric Gastroenterology, Hepatology and Nutrition , Cincinnati Children's Medical Center, University of Cincinnati School of Medicine , Cincinnati , Ohio , USA
| | - John C Magee
- University of Michigan Hospitals and Health Centers , Ann Arbor , Michigan , USA
| | - Robert M Merion
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Ronald J Sokol
- Pediatric Gastroenterology, Hepatology and Nutrition , Children's Hospital Colorado, University of Colorado School of Medicine , Aurora , Colorado , USA
| | - Benjamin L Shneider
- Division of Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Department of Pediatrics , Baylor College of Medicine , Houston , Texas , USA
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Chaidez A, Pan Z, Sundaram SS, Boster J, Lovell M, Sokol RJ, Mack CL. The discriminatory ability of FibroScan liver stiffness measurement, controlled attenuation parameter, and FibroScan-aspartate aminotransferase to predict severity of liver disease in children. Hepatol Commun 2022; 6:3015-3023. [PMID: 36069338 PMCID: PMC9592794 DOI: 10.1002/hep4.1983] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/10/2022] [Indexed: 12/14/2022] Open
Abstract
Vibration controlled transient elastography (FibroScan) is used to predict the severity of liver fibrosis and steatosis. In pediatrics, few studies have been performed directly comparing liver histologic features with FibroScan liver stiffness measurements (LSMs) and controlled attenuation parameters (CAPs). The FibroScan-aspartate aminotransferase (FAST) score, which predicts liver disease severity in adult nonalcoholic fatty liver disease (NAFLD), has not been analyzed in children. The aims of this study were to determine if LSM and CAP correlated with liver histologic fibrosis stage and steatosis grade, respectively, and to determine the predictive capacity of FAST in pediatric NAFLD. Research participants (n = 216) included those with FibroScan within 90 days of a liver biopsy. The ability of LSM, CAP, and FAST to predict severity of liver disease was analyzed by Spearman correlation, linear regression, and receiver operating characteristic and C statistic. Significant correlations were identified between LSM and Ishak fibrosis stages, with the strongest correlation occurring in the non-NAFLD group (Spearman r = 0.47, p < 0.0001). LSM adequately predicted Ishak stages F0-2 versus F3-F6 (area under the receiver operating characteristic curve [AUROC], 0.73 for all; 0.77 for non-NAFLD). CAP strongly predicted histologic steatosis grade (r = 0.84; p < 0.0001; AUROC, 0.98). FAST had acceptable discriminatory ability for significant liver disease (AUROC, 0.75). A FAST cutoff ≥0.67 had a sensitivity of 89% but a specificity of only 62% at determining significant liver disease. This study encompasses one of the largest pediatric cohorts describing the accuracy of FibroScan LSM and CAP to predict liver histologic fibrosis stage and steatosis grade, respectively. In order to determine specific LSM, CAP, and FAST cut-off values for fibrosis stages, steatosis grades, and significant liver disease, respectively, a much larger cohort is necessary and will likely entail the need for multicentered studies.
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Affiliation(s)
- Alexander Chaidez
- Section of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsPediatric Liver CenterChildren's Hospital ColoradoUniversity of Colorado School of Medicine and Anschutz Medical CampusAuroraColoradoUSA
| | - Zhaoxing Pan
- Clinical and Translational Science InstituteUniversity of Colorado School of Medicine and Anschutz Medical CampusAuroraColoradoUSA
| | - Shikha S. Sundaram
- Section of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsPediatric Liver CenterChildren's Hospital ColoradoUniversity of Colorado School of Medicine and Anschutz Medical CampusAuroraColoradoUSA
| | - Julia Boster
- Section of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsPediatric Liver CenterChildren's Hospital ColoradoUniversity of Colorado School of Medicine and Anschutz Medical CampusAuroraColoradoUSA
| | - Mark Lovell
- Department of PathologyUniversity of Colorado School of Medicine and Anschutz Medical CampusAuroraColoradoUSA
| | - Ronald J. Sokol
- Section of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsPediatric Liver CenterChildren's Hospital ColoradoUniversity of Colorado School of Medicine and Anschutz Medical CampusAuroraColoradoUSA
| | - Cara L. Mack
- Section of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsPediatric Liver CenterChildren's Hospital ColoradoUniversity of Colorado School of Medicine and Anschutz Medical CampusAuroraColoradoUSA,Department of PediatricsMedical College of WisconsinChildren's Hospital WisconsinMilwaukeeWisconsinUSA
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Bass LM, Ye W, Hawthorne K, Leung DH, Murray KF, Molleston JP, Romero R, Karpen S, Rosenthal P, Loomes KM, Wang KS, Squires RH, Miethke A, Ng VL, Horslen S, Kyle Jensen M, Sokol RJ, Magee JC, Shneider BL, Bass L, Kelly S, Riordan M, Melin‐Aldana H, Bezerra J, Bove K, Heubi J, Miethke A, Tiao G, Denlinger J, Chapman E, Sokol R, Feldman A, Mack C, Narkewicz M, Suchy F, Sundaram S, Van Hove J, Garcia B, Kauma M, Kocher K, Steinbeiss M, Lovell M, Loomes K, Piccoli D, Rand E, Russo P, Spinner N, Erlichman J, Stalford S, Pakstis D, King S, Squires R, Sindhi R, Venkat V, Bukauskas K, McKiernan P, Haberstroh L, Squires J, Rosenthal P, Bull L, Curry J, Langlois C, Kim G, Teckman J, Kociela V, Nagy R, Patel S, Cerkoski J, Molleston JP, Bozic M, Subbarao G, Klipsch A, Sawyers C, Cummings O, Horslen S, Murray K, Hsu E, Cooper K, Young M, Finn L, Kamath B, Ng V, Quammie C, Putra J, Sharma D, Parmar A, Guthery S, Jensen K, Rutherford A, Lowichik A, Book L, Meyers R, Hall T, Wang K, Michail S, Thomas D, Goodhue C, Kohli R, Wang L, Soufi N, Thomas D, Karpen S, Gupta N, Romero R, Vos MB, Tory R, Berauer J, Abramowsky C, McFall J, Shneider B, Harpavat S, Hertel P, Leung D, Tessier M, Schady D, Cavallo L, Olvera D, Banks C, Tsai C, Thompson R, Doo E, Hoofnagle J, Sherker A, Torrance R, Hall S, Magee J, Merion R, Spino C, Ye W. Risk of variceal hemorrhage and pretransplant mortality in children with biliary atresia. Hepatology 2022; 76:712-726. [PMID: 35271743 PMCID: PMC9378352 DOI: 10.1002/hep.32451] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The natural history of gastroesophageal variceal hemorrhage (VH) in biliary atresia (BA) is not well characterized. We analyzed risk factors, incidence, and outcomes of VH in a longitudinal multicenter study. APPROACH AND RESULTS Participants enrolled in either an incident (Prospective Database of Infants with Cholestasis [PROBE]) or prevalent (Biliary Atresia Study of Infants and Children [BASIC]) cohort of BA were included. Variceal hemorrhage (VH) was defined based on gastrointestinal bleeding in the presence of varices accompanied by endoscopic or nontransplant surgical intervention. Cumulative incidence of VH and transplant-free survival was compared based on features of portal hypertension (e.g., splenomegaly, thrombocytopenia) and clinical parameters at baseline in each cohort (PROBE: 1.5 to 4.5 months after hepatoportoenterostomy [HPE]; BASIC: at enrollment > 3 years of age). Analyses were conducted on 869 children with BA enrolled between June 2004 and December 2020 (521 in PROBE [262 (51%) with a functioning HPE] and 348 in BASIC). The overall incidence of first observed VH at 5 years was 9.4% (95% CI: 7.0-12.4) in PROBE and 8.0% (5.2-11.5) in BASIC. Features of portal hypertension, platelet count, total bilirubin, aspartate aminotransferase (AST), albumin, and AST-to-platelet ratio index at baseline were associated with an increased risk of subsequent VH in both cohorts. Transplant-free survival at 5 years was 45.1% (40.5-49.6) in PROBE and 79.2% (74.1-83.4) in BASIC. Two (2.5%) of 80 participants who had VH died, whereas 10 (12.5%) underwent transplant within 6 weeks of VH. CONCLUSIONS The low risk of VH and associated mortality in children with BA needs to be considered in decisions related to screening for varices and primary prophylaxis of VH.
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Affiliation(s)
- Lee M Bass
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Wen Ye
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Kieran Hawthorne
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Karen F Murray
- Division of Gastroenterology, Department of Pediatrics, Hepatology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, Washington State, USA
| | - Jean P Molleston
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, USA
| | - Rene Romero
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Saul Karpen
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Philip Rosenthal
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kasper S Wang
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Robert H Squires
- Division of 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, Pennsylvania, USA
| | - Alexander Miethke
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Vicky L Ng
- Division of GI, Hepatology and Nutrition, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Simon Horslen
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington State, USA
| | - M Kyle Jensen
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Ronald J Sokol
- Department of Pediatrics-Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - John C Magee
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Benjamin L Shneider
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
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Abstract
Liver disease in homozygous ZZ alpha-1 antitrypsin (AAT) deficiency occurs due to the accumulation of large quantities of AAT mutant Z protein polymers in the liver. The mutant Z protein folds improperly during biogenesis and is retained within the hepatocytes rather than appropriately secreted. These intracellular polymers trigger an injury cascade, which leads to liver injury. However, the clinical liver disease is highly variable and not all patients with this same homozygous ZZ genotype develop liver disease. Evidence suggests that genetic determinants of intracellular protein processing, among other unidentified genetic and environmental factors, likely play a role in liver disease susceptibility. Advancements made in development of new treatment strategies using siRNA technology, and other novel approaches, are promising, and multiple human liver disease trials are underway.
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Affiliation(s)
- Anandini Suri
- Division of Pediatric Gastroenetrology, Hepatology and Nutrition, Department of Pediatrics, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand Boulevard, St. Louis, MO 63104, USA.
| | - Dhiren Patel
- Division of Pediatric Gastroenetrology, Hepatology and Nutrition, Department of Pediatrics, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand Boulevard, St. Louis, MO 63104, USA
| | - Jeffrey H Teckman
- Division of Pediatric Gastroenetrology, Hepatology and Nutrition, Department of Pediatrics, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand Boulevard, St. Louis, MO 63104, USA
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9
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Update Alpha-1-Antitrypsin-Mangel. Monatsschr Kinderheilkd 2022. [DOI: 10.1007/s00112-022-01549-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
ZusammenfassungDer Alpha-1-Antitrypsin-Mangel (AATM) ist mit einer Prävalenz bis zu 1:2000 eine der häufigsten monogenetischen Ursachen für eine Lebertransplantation im Kindesalter. Pulmonal manifestiert sich der AATM erst im Erwachsenenalter. Er wird oft zu spät oder überhaupt nicht diagnostiziert. Die initiale Diagnostik ist mit einer Serumspiegelbestimmung einfach und günstig durchführbar. Bei Werten unter 1,1 g/l sollte eine Genotypisierung erfolgen, die im Alpha-1-Antitrypsin-Zentrum Marburg kostenfrei angeboten wird. Aufgrund des sehr heterogenen Verlaufs sollte die weiterführende Betreuung von Patienten mit AATM jedoch Spezialisten mit ausreichender Erfahrung vorbehalten bleiben. Hierfür eignen sich insbesondere die pädiatrischen Alpha-1-Center. Einen hohen Stellenwert haben die Aufklärung sowie die Aufrechterhaltung einer guten Compliance mit regelmäßigen ärztlichen Verlaufskontrollen, um eine Progredienz der Lebererkrankung zu erfassen. Neben Anamnese und körperlicher Untersuchung sind regelmäßige Blutentnahmen und Ultraschalluntersuchungen (inkl. Leberelastographie) notwendig. Therapeutisch stehen neben einer kurativen Lebertransplantation derzeit lediglich supportive Therapien zur Wahl. Sollte eine Lebertransplantation indiziert sein, ist das Langzeit-Outcome erfreulicherweise sehr gut.
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10
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Miloh T. Use of Transient Elastography in Children. Gastroenterol Hepatol (N Y) 2022; 18:114-116. [PMID: 35505818 PMCID: PMC9053504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Tamir Miloh
- Professor of Pediatrics Medical Director, Pediatric Transplant Hepatology Miami Transplant Institute Miami, Florida
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11
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Kohut TJ, Gilbert MA, Loomes KM. Alagille Syndrome: A Focused Review on Clinical Features, Genetics, and Treatment. Semin Liver Dis 2021; 41:525-537. [PMID: 34215014 DOI: 10.1055/s-0041-1730951] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Alagille syndrome (ALGS) is an autosomal dominant disorder caused by pathogenic variants in JAG1 or NOTCH2, which encode fundamental components of the Notch signaling pathway. Clinical features span multiple organ systems including hepatic, cardiac, vascular, renal, skeletal, craniofacial, and ocular, and occur with variable phenotypic penetrance. Genotype-phenotype correlation studies have not yet shown associations between mutation type and clinical manifestations or severity, and it has been hypothesized that modifier genes may modulate the effects of JAG1 and NOTCH2 pathogenic variants. Medical management is supportive, focusing on clinical manifestations of disease, with liver transplant indicated for severe pruritus, liver synthetic dysfunction, portal hypertension, bone fractures, and/or growth failure. New therapeutic approaches are under investigation, including ileal bile acid transporter (IBAT) inhibitors and other approaches that may involve targeted interventions to augment the Notch signaling pathway in involved tissues.
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Affiliation(s)
- Taisa J Kohut
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melissa A Gilbert
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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12
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Dike PN, Mahmood N, Harpavat S. Recent advances in the use of ultrasound and related techniques in diagnosing and predicting outcomes in biliary atresia. Curr Opin Pediatr 2021; 33:515-520. [PMID: 34369411 PMCID: PMC8615294 DOI: 10.1097/mop.0000000000001048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Biliary atresia (BA) is the leading cause of chronic liver disease and the most common indication for pediatric liver transplantation. The use of ultrasound (US) and related techniques continues to evolve to help diagnose BA as well as potentially to help predict outcomes after treatment with the Kasai portoenterostomy (KP). RECENT FINDINGS There are no US findings that are definitive for BA; however, signs which are consistent with BA include gallbladder abnormalities, the triangular cord sign, presence of hepatic subcapsular flow, and hilar lymphadenopathy. Elastography techniques to measure liver stiffness may also increase the diagnostic accuracy of detecting BA, particularly in older infants or without other US findings. In addition, both US and elastography are still being studied as potential methods to predict outcomes after KP such as the development of portal hypertension and the need for liver transplant. SUMMARY US findings in the diagnosis of BA are well characterized. Future studies will help determine the utility of elastography in diagnosing BA, as well as both US and elastography in monitoring and predicting disease outcomes after KP.
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Affiliation(s)
- Peace N. Dike
- Section of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, USA
| | - Nadia Mahmood
- E.B. Singleton Department of Pediatric Radiology, Texas Children’s Hospital, Houston, TX, USA
| | - Sanjiv Harpavat
- Section of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, USA
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13
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Luoto TT, Pakarinen MP. Evolving management of paediatric portal hypertension. Arch Dis Child 2021; 106:939-940. [PMID: 33692083 DOI: 10.1136/archdischild-2020-319600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/14/2021] [Accepted: 02/16/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Topi T Luoto
- Department of Pediatric Surgery, University of Helsinki Children's Hospital, Helsinki, Uusimaa, Finland .,Department of Pediatric Surgery, Tampere University Hospital, Tampere, Finland
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, University of Helsinki Children's Hospital, Helsinki, Uusimaa, Finland
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14
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Patel D, Teckman J. Liver disease with unknown etiology - have you ruled out alpha-1 antitrypsin deficiency? Ther Adv Chronic Dis 2021; 12_suppl:2040622321995684. [PMID: 34408828 PMCID: PMC8367207 DOI: 10.1177/2040622321995684] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/12/2021] [Indexed: 01/13/2023] Open
Abstract
Although a less well-known consequence of alpha-1 antitrypsin deficiency (AATD) liver disease is the second leading cause of death among patients with the condition. The alpha-1 antitrypsin (AAT) protein is produced by hepatocytes within the liver, which retain pathological variants of AAT instead of secreting the proteinase inhibitor into the systemic circulation. This intracellular retention is caused by inefficient folding and polymerization of mutant AAT and the accumulation of these AAT aggregates leads to diverse manifestations of liver disease, which can present differently in both children and adults. The progression from hepatocyte apoptosis to liver inflammation, fibrosis and cirrhosis, and liver failure is still not fully understood, but in older patients, liver disease can surpass lung disease as the principal cause of death. Liver function tests (LFTs) can measure plasma levels of liver enzymes to assess liver function but require careful interpretation. Non-invasive tests are being developed that can detect early liver disease, but liver biopsy is still the gold standard for assessing liver fibrosis once abnormal LFTs have been detected in a patient. Currently, there is no licensed treatment for AATD-related liver disease (intravenous AAT therapy is not indicated for this purpose), but liver transplantation is associated with positive outcomes and may even slow emphysema progression. Therefore, new strategies are being developed to address treatment of AATD-related liver disease, such as accelerating degradation of mutant AAT and assisting hepatocytes in the folding and secretion of mutant AAT, but these approaches remain at early stages of development.
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Affiliation(s)
- Dhiren Patel
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, St Louis University School of Medicine, St Louis, MO, USA
| | - Jeffrey Teckman
- Department of Pediatrics and Department of Biochemistry and Molecular Biology, St Louis University School of Medicine, St Louis, MO, USA
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