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Menon J, Shanmugam N, Vij M, Veerankutty FH, Rammohan A, Rela M. Simultaneous total internal biliary diversion during liver transplantation for progressive familial intrahepatic cholestasis type 1: Standard of care? Liver Transpl 2024; 30:699-706. [PMID: 38353595 DOI: 10.1097/lvt.0000000000000351] [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: 08/31/2023] [Accepted: 02/04/2024] [Indexed: 03/17/2024]
Abstract
Patients post liver transplant (LT) with progressive familial intrahepatic cholestasis type 1 (PFIC-1) often develop progressive graft steatohepatitis, intractable diarrhea, and growth failure. A total internal biliary diversion (TIBD) during an LT may prevent or reverse these adverse events. Children with PFIC-1 who underwent an LT at our institute were divided into 2 groups, A and B based on the timeline where we started offering a TIBD in association with LT. Pre-LT parameters, intraoperative details, and posttransplant complications like graft steatosis and diarrhea were also analyzed between the 2 groups, and their growth velocity was measured in the follow-up period. Of 550 pediatric LT performed between 2011 and 2022, 13 children underwent LT for PFIC-1. Group A had 7 patients (A1-A7) and group B had 6 (B1-B6). Patients A1, A4, B4, and B5 had a failed partial internal biliary diversion before offering them an LT. Patients A1, A2, and A6 in group A died in the post-LT period (2 early allograft dysfunction and 1 posttransplant lymphoproliferative disorder) whereas A3, A4, and A5 had graft steatosis in the follow-up period. A4 was offered a TIBD 4 years after LT following which the graft steatosis fully resolved. In group B, B1, B2, B5, and B6 underwent TIBD during LT, and B3 and B4 had it 24 and 5 months subsequently for intractable diarrhea and graft steatosis. None of the patients in group B demonstrated graft steatosis or diarrhea and had good growth catch-up during follow-up. We demonstrate that simultaneous TIBD in patients undergoing LT should be a standard practice as it helps dramatically improve outcomes in PFIC-1 as it prevents graft steatosis and/or fibrosis, diarrhea, and improves growth catch-up.
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Affiliation(s)
- Jagadeesh Menon
- Department of Pediatric Gastroenterology & Hepatology, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Naresh Shanmugam
- Department of Pediatric Gastroenterology & Hepatology, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Mukul Vij
- Department of Histopathology, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, Tamil Nadu, India
| | - Fadl H Veerankutty
- Department of Hepatobiliary Surgery & Liver Transplantation, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Ashwin Rammohan
- Department of Hepatobiliary Surgery & Liver Transplantation, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Mohamed Rela
- Department of Hepatobiliary Surgery & Liver Transplantation, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamil Nadu, India
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Gairola A, Wetten A, Dyson J. Sodium/bile acid co-transporter inhibitors currently in preclinical or early clinical development for the treatment of primary biliary cholangitis. Expert Opin Investig Drugs 2024; 33:485-495. [PMID: 38613839 DOI: 10.1080/13543784.2024.2343789] [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: 01/25/2024] [Accepted: 04/12/2024] [Indexed: 04/15/2024]
Abstract
INTRODUCTION Pruritus is common and often undertreated in patients with primary biliary cholangitis (PBC). Existing treatments largely have an aging and low-quality evidence base, and studies included only small numbers of patients. More recent data that has added to our understanding of pruritus treatments has often come from clinical trials where itching was a secondary outcome measure in a trial designed primarily to assess disease-modifying agents. This area represents an unmet clinical need in the management of PBC. AREAS COVERED In this manuscript, we first summarize the proposed mechanisms for PBC-related pruritus and the current treatment paradigm. We then present an appraisal of the existing pre-clinical and clinical evidence for the use of ileal bile acid transporter inhibitors (IBATis) for this indication in PBC patients. EXPERT OPINION Evidence for the efficacy of IBATis is promising but limited by the currently available volume of data. Furthermore, larger clinical trials with long-term data on efficacy, safety and tolerability are needed to confirm the role of using IBATis in clinical practice and their place on the itch treatment ladder. Additional focus should also be given to exploring the disease-modifying potential of IBATis in PBC.
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Affiliation(s)
- Abhishek Gairola
- Liver Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Aaron Wetten
- Liver Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Jessica Dyson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
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Hüpper MN, Pichler J, Huber WD, Heilos A, Schaup R, Metzelder M, Langer S. Surgical versus Medical Management of Progressive Familial Intrahepatic Cholestasis-Case Compilation and Review of the Literature. CHILDREN (BASEL, SWITZERLAND) 2023; 10:949. [PMID: 37371180 DOI: 10.3390/children10060949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/13/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
(1) Background: Progressive familial intrahepatic cholestasis (PFIC) is a rare cause of liver failure. Surgical biliary diversion (SBD) and ileal bile salt inhibitors (IBAT) can delay or prevent liver transplantation (LTX). A comparison of the two methodologies in the literature is lacking. The combination has not been investigated. (2) Methods: We performed a literature survey on medical and surgical treatments for PFIC and reviewed the charts of our patients with PFIC of a tertiary hospital. The end points of our analysis were a decrease in serum bile acid (sBA) levels, reduction of pruritus and delay or avoidance of (LTX). (3) Results: We included 17 case series on SBD with more than 5 patients and a total of 536 patients. External or internal SBD, either conventional or minimally invasive, can reduce pruritus and sBA, but not all PFIC types are suitable for SBD. Six publications described the use of two types of IBAT in PFIC with a total of 118 patients. Treatment response was dependent on genetic type and subtype. Patients with PFIC 2 (nt-BSEP) showed the best response to treatment. Four out of eleven PFIC patients underwent SBD at our centre, with two currently receiving IBAT. (4) Conclusions: Limited data on IBAT in selected patients with PFIC show safety and effectiveness, although surgical methods should still be considered as a successful bridging procedure. Further studies to evaluate a possible combination of IBAT and SBD in PFIC are warranted and treatment decision should be discussed in an interdisciplinary board.
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Affiliation(s)
- Maria Noelle Hüpper
- Department of Paediatric Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Judith Pichler
- Department of Paediatric Gastroenterology, Department of Paediatrics, Medical University of Vienna, 1090 Vienna, Austria
| | - Wolf-Dietrich Huber
- Department of Paediatric Gastroenterology, Department of Paediatrics, Medical University of Vienna, 1090 Vienna, Austria
| | - Andreas Heilos
- Department of Paediatric Gastroenterology, Department of Paediatrics, Medical University of Vienna, 1090 Vienna, Austria
| | - Rebecca Schaup
- Department of Paediatric Gastroenterology, Department of Paediatrics, Medical University of Vienna, 1090 Vienna, Austria
| | - Martin Metzelder
- Department of Paediatric Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Sophie Langer
- Department of Paediatric Surgery, Medical University of Vienna, 1090 Vienna, Austria
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Ebhohon E, Chung RT. Systematic review: efficacy of therapies for cholestatic pruritus. Therap Adv Gastroenterol 2023; 16:17562848231172829. [PMID: 37255856 PMCID: PMC10226044 DOI: 10.1177/17562848231172829] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 04/13/2023] [Indexed: 06/01/2023] Open
Abstract
Background Pruritus is a symptom of several cholestatic liver diseases (CLDs) that can impair health-related quality of life (HRQoL). Despite evidence-based guideline therapy, managing cholestatic pruritus (CP) remains challenging, thus making the need for newer, more effective therapeutic agents more evident. Objective Our study evaluated the efficacy of existing CP therapies. Design Systematic review. Data sources From inception until March 2023, we conducted a comprehensive search of MEDLINE, Cochrane, EMBASE, Scopus, ClinicalTrial.gov, and other sources, including pharmaceutical webpages and conference proceedings published in English that reported on CP interventions. Methods Two reviewers independently conducted screening and full-text review of articles with extraction conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The methodological quality of studies included in our qualitative synthesis was assessed by using the Cochrane ROBINS-I and ROBINS-II tools for interventional studies and the National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The primary outcome assessed in our systematic review was the severity of CP after therapy. Results Of 3293 screened articles, 92 studies were eligible for inclusion in the qualitative synthesis. Some patients' HRQoL improved with evidence-based standard therapy. Others, particularly those with severe and refractory CP, often required conversion to or addition of experimental noninvasive (e.g., ondansetron) or extracorporeal liver support to alleviate CP. In addition, studies investigating a newer class drug, the ileal bile acid transporter inhibitor (IBATi), demonstrate its effectiveness in reducing serum bile acid and alleviating CP with sustained improvement noted in patients with the inherited childhood cholestatic disorders - progressive familial intrahepatic cholestasis and Alagille syndrome. Conclusion Our findings consolidate data on the efficacy of guideline-based approaches and newer therapies for CP. While the initial findings are promising, additional clinical trials will be needed to determine the full extent of IBATi's efficacy and potential use in treating other common CLDs. These results provide a foundation for future research and highlight the need for continued investigation into the management and treatment of CLDs.
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Affiliation(s)
| | - Raymond T. Chung
- Gastrointestinal Division, Liver Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Ileal Bile Acid Transporter Blockers for Cholestatic Liver Disease in Pediatric Patients with Alagille Syndrome: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11247526. [PMID: 36556142 PMCID: PMC9784790 DOI: 10.3390/jcm11247526] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Alagille syndrome (ALGS) is a rare, debilitating inheritable disease that is associated with refractory pruritus due to chronic cholestasis. The following systemic review and meta-analysis presents the latest evidence for ileal bile acid transport (IBAT) blockers in AGLS patients in order to improve their efficacy. This study adhered to PRISMA 2020 Statement guidelines. A systematic search of PubMed/MEDLINE, Web of Science, Scopus, and the Cochrane library was conducted from inception until 23 October 2022. A combination of the following keywords was used: Alagille syndrome, therapeutics, treatment, therapy. Meta-analytical outcomes included effect directions of end-line changes in serum bile acids (sBAs), Itch Scale scores (ItchRO), Multidimensional Fatigue Scale scores, pediatric quality of life (QL), alanine aminotransferase (ALT), and total bilirubin. A total of 94 patients across four trials were enrolled and received maralixibat, odevixibat, or a placebo. There was a significant reduction in ItchRO scores by 1.8 points, as well as in sBAs by 75.8 μmol/L. Both the Multidimensional Fatigue Scale and Pediatric QL scale were also improved by 11.4 and 8.3 points, respectively. However, ALT levels were raised by 40 U/L. The efficacy of IBAT inhibitors across current trials was noted. Future trials may focus on the optimization of dosing regimens, considering gastrointestinal side effects and drug-induced ALT elevation in AGLS patients.
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Öztürk H, Sarı S, Sözen H, Eğritaş Gürkan Ö, Dalgıç B, Dalgıç A. Long-Term Outcomes of Patients With Progressive Familial Intrahepatic Cholestasis After Biliary Diversion. EXP CLIN TRANSPLANT 2022; 20:76-80. [PMID: 35570606 DOI: 10.6002/ect.pediatricsymp2022.o26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Progressive familial intrahepatic cholestasis is a heterogeneous group of genetic disorders characterized by disrupted bile homeostasis. Patients with this disease typically present with cholestasis and pruritus early in life and often progress to end-stage liver disease. The clinical symptoms that patients with progressive familial intrahepatic cholestasis encounter are usually refractory to medical treatment. Although the effects of biliary diversion surgery on native liver survival are not exactly known, this procedure may provide a positive impact on pruritus and laboratory parameters in these patients. MATERIALS AND METHODS We retrospectively evaluated the clinical and laboratory characteristics of patients with progressive familial intrahepatic cholestasis who underwent partial external biliary diversion between 2002 and 2020 at our center. Diagnosis of progressive familial intrahepatic cholestasis was made by clinical, biochemical, and histopathological characteristics as well as genetic testing. RESULTS Nine patients were included in the study. Five patients required liver transplant during follow-up, with 4 having liver transplant as a result of endstage liver disease (median interval of 5 years). In 1 patient, partial external biliary diversion was performed 1.5 years after liver transplant for severe diarrhea, metabolic acidosis, and hepatic steatosis. Four patients did not require liver transplant during follow-up (median follow-up time of 7.6 years). Pruritus responded well to partial external biliary diversion in all patients. Among laboratory values evaluated 6 months after biliary diversion, only albumin showed significant improvement. CONCLUSIONS Partial external biliary diversion had favorable results on long-term follow-up. This procedure can provide the relief of pruritus and delay the requirement for liver transplant in patients with progressive familial intrahepatic cholestasis. In our view, partial external biliary diversion should be considered the first-line surgical management for patients with this disease.
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Affiliation(s)
- Hakan Öztürk
- From the Department of Pediatric Gastroenterology, Gazi University, Ankara, Turkey
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Dervout C, Boulais N, Barnetche T, Nousbaum JB, Brenaut E, Misery L. Efficacy of Treatments for Cholestatic Pruritus: A Systemic Review and Meta-analysis. Acta Derm Venereol 2022; 102:adv00653. [PMID: 35088869 PMCID: PMC9609979 DOI: 10.2340/actadv.v102.310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Cholestatic itch is a disabling symptom that may be secondary to liver or biliary diseases. Management of cholestatic pruritus is complex. A systematic review and meta-analysis on the efficacy of treatments for cholestatic pruritus were performed. PubMed and Cochrane Library were searched using the algorithm “(hepatitis OR cholestatic OR liver) AND (pruritus OR itch) AND (management OR treatment OR treatments)” for 1975–2019. Of the 2,264 articles identified, 93 were included in a systematic review and 15 in a meta-analysis (studies evaluating pruritus with a visual analogue scale). Some treatments act by reducing levels of pruritogens in the enterohepatic cycle, others modify the metabolism or secretion of these pruritogens, or act on pruritus pathways. A further possible treatment is albumin dialysis. However, due to many heterogeneities in the reviewed studies it is difficult to identify and recommend an optimum treatment. Only 15 studies were included in the meta-analysis, due to the small number of randomized studies using a visual analogue scale.
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Affiliation(s)
| | | | | | | | - Emilie Brenaut
- Department of Dermatology, University Hospital, FR-29609 Brest, France.
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Bolia R, Goel AD, Sharma V, Srivastava A. Biliary diversion in progressive familial intrahepatic cholestasis: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2022; 16:163-172. [PMID: 35051344 DOI: 10.1080/17474124.2022.2032660] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Biliary diversion (BD) is indicated in progressive familial intrahepatic cholestasis (PFIC) with refractory pruritus. Three types-partial external biliary drainage (PEBD), partial internal biliary drainage (PIBD), and ileal exclusion (IE) are described, with no consensus about the relative efficacy of these procedures. METHODS PubMed, Scopus, and Google Scholar were searched for publications on PFIC and BD. Improvement in pruritus, serum bile acid (BA), and need for liver transplantation (LT) were compared between the various BD procedures. RESULTS 25 studies [424 children (PEBD-301, PIBD-93, IE-30)] were included. Pruritus resolved in 59.5% [PIBD:72% (95%CI 43-96%), PEBD:57% (95%CI 43-71%) and IE:48% (95%CI 14-82%)] cases. Significant overlap in confidence intervals indicated no significant differences. Absolute decrease in BA (AUROC-0.72) and bilirubin (AUROC-0.69) discriminated responders and non-responders. Eventually, 27% required LT: PIBD 10.7%, PEBD32%, IE 27%. The post-operative BA (AUROC-0.9) and bilirubin (AUROC-0.85) determined need for LT. Complications were commoner in PEBD than PIBD (38% vs 21.8%: p=0.02). CONCLUSION 59.5% children have pruritus relief after BD and 27% need LT. PIBD has lower complications and LT requirement than PEBD. However, this requires cautious interpretation as the 2 groups differed in PFIC type and follow-up duration.
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Affiliation(s)
- Rishi Bolia
- Division of Paediatric Gastroenterology, Department of Paediatrics, All India Institute of Medical Sciences, Rishikesh, India
| | - Akhil Dhanesh Goel
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Vishakha Sharma
- Division of Paediatric Gastroenterology, Department of Paediatrics, All India Institute of Medical Sciences, Rishikesh, India
| | - Anshu Srivastava
- Department of Paediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Masahata K, Ueno T, Bessho K, Kodama T, Tsukada R, Saka R, Tazuke Y, Miyagawa S, Okuyama H. Clinical outcomes of surgical management for rare types of progressive familial intrahepatic cholestasis: a case series. Surg Case Rep 2022; 8:10. [PMID: 35024979 PMCID: PMC8758805 DOI: 10.1186/s40792-022-01365-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/10/2022] [Indexed: 12/14/2022] Open
Abstract
Background Progressive familial intrahepatic cholestasis (PFIC) is a heterogeneous group of genetic autosomal recessive diseases that cause severe cholestasis, which progresses to cirrhosis and liver failure, in infancy or early childhood. We herein report the clinical outcomes of surgical management in patients with four types of PFIC. Case presentation Six patients diagnosed with PFIC who underwent surgical treatment between 1998 and 2020 at our institution were retrospectively assessed. Living-donor liver transplantation (LDLT) was performed in 5 patients with PFIC. The median age at LDLT was 4.8 (range: 1.9–11.4) years. One patient each with familial intrahepatic cholestasis 1 (FIC1) deficiency and bile salt export pump (BSEP) deficiency died after LDLT, and the four remaining patients, one each with deficiency of FIC1, BSEP, multidrug resistance protein 3 (MDR3), and tight junction protein 2 (TJP2), survived. One FIC1 deficiency recipient underwent LDLT secondary to deterioration of liver function, following infectious enteritis. Although he underwent LDLT accompanied by total external biliary diversion, the patient died because of PFIC-related complications. The other patient with FIC1 deficiency had intractable pruritus and underwent partial internal biliary diversion (PIBD) at 9.8 years of age, pruritus largely resolved after PIBD. One BSEP deficiency recipient, who had severe graft damage, experienced recurrence of cholestasis due to the development of antibodies against BSEP after LDLT, and eventually died due to graft failure. The other patient with BSEP deficiency recovered well after LDLT and there was no evidence of posttransplant recurrence of cholestasis. In contrast, recipients with MDR3 or TJP2 deficiency showed good courses and outcomes after LDLT. Conclusions Although LDLT was considered an effective treatment for PFIC, the clinical courses and outcomes after LDLT were still inadequate in patients with FIC1 and BSEP deficiency. LDLT accompanied by total biliary diversion may not be as effective for patients with FIC1 deficiency.
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Affiliation(s)
- Kazunori Masahata
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takehisa Ueno
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Kazuhiko Bessho
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tasuku Kodama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Ryo Tsukada
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Ryuta Saka
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shuji Miyagawa
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Ahmed W, Jeyaraj R, Reffitt D, Devlin J, Suddle A, Hunt J, Heneghan MA, Harrison P, Joshi D. Nasobiliary drainage: an effective treatment for pruritus in cholestatic liver disease. Frontline Gastroenterol 2022; 13:416-422. [PMID: 36051950 PMCID: PMC9380771 DOI: 10.1136/flgastro-2021-102025] [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: 10/10/2021] [Accepted: 12/21/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Nasobiliary drains (NBDs) have been successfully used to manage intrahepatic cholestasis, bile leaks and obstructive cholangitis. It allows external drainage of bile, bypassing the ileum where bile salts are reabsorbed. We assessed the utility of placement with effect on markers of cholestasis and patient symptoms. METHODS Consecutive patients undergoing NBD over 12 years for the management of pruritus were retrospectively analysed. Recorded variables included patient demographics, procedural characteristics and response to therapy. RESULTS Twenty-three patients (14, 61% male) underwent 30 episodes of NBD. The median age was 26 years old (range 2-67 years old). A single procedure was carried out in 20. One patient each had two, three and five episodes of NBD. The most common aetiologies were hereditary cholestatic disease (n=17, 74%) and drug-induced cholestasis (n=5, 22%),NBD remained in situ for a median of 8 days (range 1-45 days). Significant improvement in bilirubin was seen at 7 days post-NBD (p=0.0324), maintained at day 30 (335 μmol/L vs 302 µmol/L vs 167 µmol/L). There was symptomatic improvement in pruritus in 20 (67%, p=0.0494) episodes. One patient underwent NBD during the first trimester of pregnancy after medical therapy failure with a good symptomatic response. The catheters were well tolerated in 27 (90%) of cases. Mild pancreatitis occurred in 4 (13%) cases. CONCLUSION NBD can be used to provide symptomatic improvement to patients with pruritus associated with cholestasis. It is well tolerated by patients. They can be used in pregnancy where medical management has failed.
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Affiliation(s)
- Wafaa Ahmed
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Rebecca Jeyaraj
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - David Reffitt
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - John Devlin
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Abid Suddle
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - John Hunt
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Phillip Harrison
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital NHS Trust, London, UK
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Varol Fİ, Selimoğlu MA, Güngör Ş, Yılmaz S, Tekedereli İ. Single-center experience in management of progressive familial intrahepatic cholestasis. Arab J Gastroenterol 2021; 22:310-315. [PMID: 34840097 DOI: 10.1016/j.ajg.2021.05.021] [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: 10/01/2020] [Revised: 05/08/2021] [Accepted: 05/31/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND STUDY AIMS Progressive familial intrahepatic cholestasis (PFIC) is an autosomal recessively inherited disease that causes intrahepatic-hepatocellular cholestasis. PFIC constitutes approximately 10-15% of cholestatic liver diseases in children. The aim of this study is to draw attention to this group of diseases, which pose a higher risk, in societies where consanguineous marriage is more common, and to share our experiences since the studies in the literature, regarding this group of diseases are case series with small number of patients. PATIENTS AND METHODS This cross-sectional study was conducted on 34 patients who were admitted with jaundice and diagnosed by genetic analysis, between January 2015 and July 2020. RESULTS We found 17.6% of patients with PFIC type 1, 55.9% patients had PFIC type 2, 14.7% patients had PFIC type 3, 8.8% patients had PFIC type 4 and 2.9% patients had PFIC type 5. Partial internal biliary diversion was performed in 5 (14.7%) patients, who had severe itching during follow-up, did not respond to medical treatment, and did not have significant fibrosis in liver biopsy yet. The degree of itching before PIBD was rated as +4 (cutaneous erosion, bleeding and scarring), in 5 patients and the rates were 0 (absent) in two patients, and +1 (mild itching) in 3 patients, 6 months after PIBD, these differences were statistically significant(p = 0.027). The mean weight z score was-1.43 (-3.72-+0.73), before PIBD, while it was 0.39(-1.86 -+2.45), six months after PIBD; the diference was statistically significant(p = 0.043). Liver transplantation was performed in 12 (35.3%) patients with significant fibrosis in liver biopsy and developing signs of portal hypertension. CONCLUSION The PFIC disease group is a heterogeneous disease group that is difficult to diagnose and treat. It should be considered in patients with cholestasis and/or pruritus and those with a history of consanguineous marriage between parents and death of a sibling with similar clinical symptoms.
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Affiliation(s)
- Fatma İlknur Varol
- Departments of Pediatric Gastroenterology, Hepatology, and Nutrition, Inonu University, Faculty of Medicine, Malatya, Turkey.
| | - Mukadder Ayşe Selimoğlu
- Departments of Pediatric Gastroenterology, Hepatology, and Nutrition, Inonu University, Faculty of Medicine, Malatya, Turkey
| | - Şükrü Güngör
- Departments of Pediatric Gastroenterology, Hepatology, and Nutrition, Inonu University, Faculty of Medicine, Malatya, Turkey
| | - Sezai Yılmaz
- General Surgery, Inonu University, Faculty of Medicine, Malatya, Turkey
| | - İbrahim Tekedereli
- Inonu University, Faculty of Medicine, Department of Medical Biology and Genetics, Malatya, Turkey
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Baumann U, Sturm E, Lacaille F, Gonzalès E, Arnell H, Fischler B, Jørgensen MH, Thompson RJ, Mattsson JP, Ekelund M, Lindström E, Gillberg PG, Torfgård K, Soni PN. Effects of odevixibat on pruritus and bile acids in children with cholestatic liver disease: Phase 2 study. Clin Res Hepatol Gastroenterol 2021; 45:101751. [PMID: 34182185 DOI: 10.1016/j.clinre.2021.101751] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 05/05/2021] [Accepted: 06/02/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Ileal bile acid transporter inhibition is a novel therapeutic concept for cholestatic pruritus and cholestatic liver disease progression. Odevixibat, a potent, selective, reversible ileal bile acid transporter inhibitor, decreases enteric bile acid reuptake with minimal systemic exposure. Oral odevixibat safety, tolerability, and efficacy in pediatric patients with cholestatic liver disease and pruritus were evaluated. PATIENTS AND METHODS In this phase 2, open-label, multicenter study, children received 10‒200 μg/kg oral odevixibat daily for 4 weeks. Changes in serum bile acid levels (primary efficacy endpoint), pruritus, and sleep disturbance were explored. RESULTS Twenty patients were enrolled (8 females; 1‒17 years; 4 re-entered at a different dose). Diagnoses included progressive familial intrahepatic cholestasis (n = 13; 3 re-entries), Alagille syndrome (n = 6), biliary atresia (n = 3), and other intrahepatic cholestasis causes (n = 2; 1 re-entry). Mean baseline serum bile acid levels were high (235 µmol/L; range, 26‒564) and were reduced in the majority (-123.1 μmol/L; range, -394 to 14.5, reflecting reductions of up to 98%). Patient-reported diary data documented improved pruritus (3 scales) and sleep. With 100 μg/kg, mean (SEM) decrease was 2.8 (1.1) points for pruritus (visual analogue itch scale 0-10) and 2.9 (0.9) points for sleep disturbance (Patient-Oriented Scoring Atopic Dermatitis scale 0-10). Reduced pruritus correlated significantly with reduced serum bile acids (P ≤ 0.007). Significant correlations were also observed between autotaxin levels and pruritus. All patients completed the study. No serious adverse events were treatment related; most adverse events, including increased transaminases, were transient. CONCLUSIONS Orally administered odevixibat was well tolerated, reduced serum bile acids, and improved pruritus and sleep disturbance in children with cholestatic diseases.
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Affiliation(s)
- Ulrich Baumann
- Paediatric Gastroenterology and Hepatology, Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany.
| | - Ekkehard Sturm
- Pediatric Gastroenterology and Hepatology, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Florence Lacaille
- Pediatric Gastroenterology-Hepatology-Nutrition, Necker-Enfants Malades Hospital, Paris, France
| | - Emmanuel Gonzalès
- Hépatologie et Transplantation Hépatique Pédiatriques, Centre de Référence de l'Atrésie des Voies Biliaires et des Cholestases Génétiques, FSMR FILFOIE, ERN RARE LIVER, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Hépatinov, Inserm U 1193, Paris, France
| | - Henrik Arnell
- Pediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Womens and Childrens Health, Karolinska Institutet, Stockholm, Sweden
| | - Björn Fischler
- Pediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Womens and Childrens Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Richard J Thompson
- Institute of Liver Studies, King's College London, London, United Kingdom
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Bjørnland K, Hukkinen M, Gatzinsky V, Arnell H, Pakarinen MP, Almaas R, Svensson JF. Partial Biliary Diversion May Promote Long-Term Relief of Pruritus and Native Liver Survival in Children with Cholestatic Liver Diseases. Eur J Pediatr Surg 2021; 31:341-346. [PMID: 32707578 DOI: 10.1055/s-0040-1714657] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Rare cholestatic liver diseases may cause debilitating pruritus in children. Partial biliary diversion (PBD) may relieve pruritus and postpone liver transplantation which is the only other alternative when conservative treatment fails. The aim was to report long-term outcome after PBD in a population of 26 million people during a 25-year period. MATERIALS AND METHODS This is an international, multicenter retrospective study reviewing medical journals. Complications were graded according to the Clavien-Dindo classification system. RESULTS Thirty-three patients, 14 males, underwent PBD at a median of 1.5 (0.3-13) years at four Nordic pediatric surgical centers. Progressive familial intrahepatic cholestasis was the most common underlying condition. Initially, all patients got external diversion, either cholecystojejunostomy (25 patients) or button placed in the gallbladder or a jejunal conduit. Early complications occurred in 14 (42%) patients, of which 3 were Clavien-Dindo grade 3. Long-term stoma-related complications were common (55%). Twenty secondary surgeries were performed due to stoma problems such as prolapse, stricture, and bleeding, or conversion to another form of PBD. Thirteen children have undergone liver transplantation, and two are listed for transplantation due to inefficient effect of PBD on pruritus. Serum levels of bile acids in the first week after PBD construction were significantly lower in patients with good relief of pruritus than in those with poor effect (13 [2-192] vs. 148 [5-383] μmol/L; p = 0.02). CONCLUSION PBD may ensure long-term satisfactory effect on intolerable pruritus and native liver survival in children with cholestatic liver disease. However, stoma-related problems and reoperations are common.
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Affiliation(s)
- Kristin Bjørnland
- Section of Pediatric Surgery, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway
| | - Maria Hukkinen
- Department of Pediatric Surgery, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
| | - Vladimir Gatzinsky
- Department of Pediatric Surgery, The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Henrik Arnell
- Department of Pediatrics, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
| | - Runar Almaas
- Department of Pediatrics, Oslo universitetssykehus, Rikshospitalet, University of Oslo, Oslo, Norway
| | - Jan F Svensson
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
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14
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Chronic Kidney Disease-Associated Itch (CKD-aI) in Children-A Narrative Review. Toxins (Basel) 2021; 13:toxins13070450. [PMID: 34209560 PMCID: PMC8309841 DOI: 10.3390/toxins13070450] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 06/26/2021] [Accepted: 06/28/2021] [Indexed: 01/08/2023] Open
Abstract
Chronic kidney disease (CKD) is a condition of widespread epidemiology and serious consequences affecting all organs of the organism and associated with significant mortality. The knowledge on CKD is rapidly evolving, especially concerning adults. Recently, more data is also appearing regarding CKD in children. Chronic itch (CI) is a common symptom appearing due to various underlying dermatological and systemic conditions. CI may also appear in association with CKD and is termed chronic kidney disease-associated itch (CKD-aI). CKD-aI is relatively well-described in the literature concerning adults, yet it also affects children. Unfortunately, the data on paediatric CKD-aI is particularly scarce. This narrative review aims to describe various aspects of CKD-aI with an emphasis on children, based on the available data in this population and the data extrapolated from adults. Its pathogenesis is described in details, focusing on the growing role of uraemic toxins (UTs), as well as immune dysfunction, altered opioid transmission, infectious agents, xerosis, neuropathy and dialysis-associated aspects. Moreover, epidemiological and clinical aspects are reviewed based on the few data on CKD-aI in children, whereas treatment recommendations are proposed as well, based on the literature on CKD-aI in adults and own experience in managing CI in children.
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15
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Nasobiliary drainage prior to surgical biliary diversion in progressive familial intrahepatic cholestasis type II. Eur J Pediatr 2020; 179:1547-1552. [PMID: 32291498 DOI: 10.1007/s00431-020-03646-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/18/2020] [Accepted: 03/27/2020] [Indexed: 12/12/2022]
Abstract
Progressive familial intrahepatic cholestasis (PFIC) can cause intense pruritus that is refractory to medical therapy. Surgical biliary diversion techniques, including partial internal biliary diversion (PIBD), have been developed over the years to relieve pruritus without requiring liver transplantation. No clinical or genetic features can currently predict postoperative pruritus response. We present three PFIC type 2 (PIFC 2) patients who underwent transient endoscopic nasobiliary drainage (NBD) prior to PIBD surgery. Two patients repeatedly responded to NBD and presented with complete pruritus resolution after subsequent PIBD. NBD failed technically in the third patient, and PIBD was partially successful. Mild post-endoscopic biological pancreatitis occurred in 2/6 NBD procedures and resolved spontaneously. The only adverse effect observed within 7 years post-PIBD was very mild transient osmotic diarrhea.Conclusion: Our limited data suggest that NBD is a safe and effective way to predict pruritus response before performing permanent biliary diversion surgery in PFIC patients. What is Known: • Surgical biliary diversion techniques have been developed to relieve intractable pruritus in progressive familial intrahepatic cholestasis (PFIC). • No clinical or genetic features can currently predict pruritus response to surgery. What is New: • Our data suggest that nasobiliary drainage could be a safe and effective tool to predict pruritus response to biliary diversion and avoid unnecessary surgery in PFIC patients.
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16
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Abstract
Progressive familial intrahepatic cholestasis (PFIC) and Alagille syndrome (AS) are conditions caused by either an autosomal recessive or an autosomal dominant genetic defect, and they are both characterized by cholestasis, jaundice, and severe debilitating pruritus refractory to medical management. Before the advent of liver transplantation, most PFIC patients would die from end-stage liver disease in the first decade of life. Although liver transplantation has led to patients' survival, disease recurrence (PFIC-2) and severe extra-hepatic manifestations of the disease (PFIC-1) occurred post transplant. In the late 1980s, Whitington described the use of partial external biliary diversion in PFIC and AS patients as a successful way to improve symptoms and decrease circulating bile acid serum concentrations. Since then, other diversion techniques have been described (ileal exclusion and partial internal biliary diversion). These techniques have the benefit of avoiding a stoma, but equivalent results have not been demonstrated (recurrence of cholestasis after ileal exclusion, limited follow up after internal biliary diversion). Overall, studies have showed that biliary diversions in children with cholestasis are safe procedures with low morbidity and mortality, and that they can reduce inflammation and ongoing liver injury, therefore delaying or avoiding the need for liver transplantation in some patients.
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17
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Kamath BM, Stein P, Houwen RHJ, Verkade HJ. Potential of ileal bile acid transporter inhibition as a therapeutic target in Alagille syndrome and progressive familial intrahepatic cholestasis. Liver Int 2020; 40:1812-1822. [PMID: 32492754 PMCID: PMC7496162 DOI: 10.1111/liv.14553] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/15/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022]
Abstract
Alagille syndrome (ALGS) and progressive familial intrahepatic cholestasis (PFIC) are rare, inherited cholestatic liver disorders that manifest in infants and children and are associated with impaired bile flow (ie cholestasis), pruritus and potentially fatal liver disease. There are no effective or approved pharmacologic treatments for these diseases (standard medical treatments are supportive only), and new, noninvasive options would be valuable. Typically, bile acids undergo biliary secretion and intestinal reabsorption (ie enterohepatic circulation). However, in these diseases, disrupted secretion of bile acids leads to their accumulation in the liver, which is thought to underlie pruritus and liver-damaging inflammation. One approach to reducing pathologic bile acid accumulation in the body is surgical biliary diversion, which interrupts the enterohepatic circulation (eg by diverting bile acids to an external stoma). These procedures can normalize serum bile acids, reduce pruritus and liver injury and improve quality of life. A novel, nonsurgical approach to interrupting the enterohepatic circulation is inhibition of the ileal bile acid transporter (IBAT), a key molecule in the enterohepatic circulation that reabsorbs bile acids from the intestine. IBAT inhibition has been shown to reduce serum bile acids and pruritus in trials of paediatric cholestatic liver diseases. This review explores the rationale of inhibition of the IBAT as a therapeutic target, describes IBAT inhibitors in development and summarizes the current data on interrupting the enterohepatic circulation as treatment for cholestatic liver diseases including ALGS and PFIC.
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Affiliation(s)
- Binita M. Kamath
- The Hospital for Sick ChildrenTorontoONCanada
- University of TorontoTorontoONCanada
| | | | | | - Henkjan J. Verkade
- University of GroningenBeatrix Children’s Hospital/University Medical Center GroningenGroningenThe Netherlands
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18
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Verkade HJ, Thompson RJ, Arnell H, Fischler B, Gillberg PG, Mattsson JP, Torfgård K, Lindström E. Systematic Review and Meta-analysis: Partial External Biliary Diversion in Progressive Familial Intrahepatic Cholestasis. J Pediatr Gastroenterol Nutr 2020; 71:176-183. [PMID: 32433433 DOI: 10.1097/mpg.0000000000002789] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES We assessed available data on impact of partial external biliary diversion (PEBD) surgery on clinical outcomes in patients with progressive familial intrahepatic cholestasis (PFIC). METHODS We performed a systematic literature review (PubMed) and meta-analysis to evaluate relationships between liver biochemistry parameters (serum bile acids, bilirubin, and alanine aminotransferase [ALT]) and early response (pruritus improvement) or long-term outcomes (need for liver transplant) in patients with PFIC who underwent PEBD. RESULTS Searches identified 175 publications before September 2018; 16 met inclusion criteria. Receiver operating characteristic (ROC) analysis examined ability of liver biochemistry parameters to discriminate patients who demonstrated early and long-term response to PEBD from those who did not. Regarding pruritus improvement in 155 included patients in aggregate, 104 (67%) were responders, 14 (9%) had partial response, and 37 (24%) were nonresponders. In ROC analyses of individual patient data, post-PEBD serum concentration of bile acids, in particular, could discriminate responders from nonresponders for pruritus improvement (area under the curve, 0.99; P < 0.0001; n = 42); to a lesser extent, this was also true for bilirubin (0.87; P = 0.003; n = 31), whereas ALT could not discriminate responders from nonresponders for pruritus improvement (0.74; P = 0.06; n = 28). Reductions from pre-PEBD values in serum bile acid concentration (0.89; P = 0.0003; n = 32) and bilirubin (0.98; P = 0.002; n = 18) but not ALT (0.62; P = 0.46; n = 18) significantly discriminated decreased aggregate need for liver transplant. CONCLUSION Changes in bile acids seem particularly useful in discriminating early and long-term post-PEBD outcomes and may be potential biomarkers of response to interruption of enterohepatic circulation in patients with PFIC.
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Affiliation(s)
- Henkjan J Verkade
- Department of Pediatrics, University of Groningen, Beatrix Children's Hospital/University Medical Center Groningen, Groningen, The Netherlands
| | - Richard J Thompson
- Institute of Liver Studies, King's College London, London, United Kingdom
| | - Henrik Arnell
- Pediatric Gastroenterology, Hepatology and Nutrition, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm
| | - Björn Fischler
- Pediatric Gastroenterology, Hepatology and Nutrition, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm
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Foroutan HR, Bahador A, Ghanim SM, Dehghani SM, Anbardar MH, Fattahi MR, Forooghi M, Azh O, Tadayon A, Sherafat A, Yaghoobi AA, Ashraf MA. Effects of partial internal biliary diversion on long-term outcomes in patients with progressive familial intrahepatic cholestasis: experience in 44 patients. Pediatr Surg Int 2020; 36:603-610. [PMID: 32206891 DOI: 10.1007/s00383-020-04641-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE Progressive familial intrahepatic cholestasis (PFIC) is a hereditary disease characterized by cholestasis, which may cause jaundice, severe pruritus, and cirrhosis in the later stages. By the invention of biliary diversion methods, these patients were prevented from undergoing liver transplant. Using biliary diversion techniques, the entero-hepatic cycle was interrupted. This lowers the bile acid pool and resolves the pruritus. Herein, we report 44 cases of PFIC who underwent partial internal biliary diversion (PIBD) and long-term follow-up of these children. This comprises the largest case series of PIBD. METHODS All patients were diagnosed by liver biopsy as PFIC before the operation. All underwent cholecysto colic bypass by jejunal interposition due to severe pruritus unresponsive to medication. Laboratory blood tests, sonography, and physical exam were done before and after the operation once every 3 months. Besides, a questionnaire was designed to ask the patients about the symptoms after the operation, and a pruritus score was measured using the 5D-itch scale. RESULTS 44 children (25 boys, 19 girls), between 1.75 and 27.5 years (at the time of this study) were followed for a median period of 54 months. Age at operation ranged from 2 months to 18 years, with a median of 29 months. Of these children, 14 were lost to follow up. Results showed a significant decrease in pruritus and sleep disturbance after the surgery (p < 0.001). Also, jaundice decreased from 82.1 before to 7.1% following the surgery. 50% of the patients became medication-free at follow-up. CONCLUSION PIBD is a safe procedure which helps non-cirrhotic children preserve their liver function. Therefore, PIBD prevents them from undergoing liver transplant. Effective results were achieved in terms of severe pruritus and jaundice, and children were able to regain their sleep patterns. It also avoided external stoma, which is more convenient from the patient's point of view.
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Affiliation(s)
- Hamid Reza Foroutan
- Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pediatric Surgery, Nemazee Hospital, Shiraz University of Medical Sciences, Zand St., 71 32326645, Shiraz, Iran
| | - Ali Bahador
- Department of Pediatric Surgery, Nemazee Hospital, Shiraz University of Medical Sciences, Zand St., 71 32326645, Shiraz, Iran
| | - Sultan Mohsin Ghanim
- Department of Pediatric Surgery, Nemazee Hospital, Shiraz University of Medical Sciences, Zand St., 71 32326645, Shiraz, Iran
| | - Seyed Mohsen Dehghani
- Gastroenterohepatology Research Center, Department of Pediatric Gastroenterology, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Mohammad Reza Fattahi
- Department of Gastroenterology, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehdi Forooghi
- Department of Pediatric Surgery, Nemazee Hospital, Shiraz University of Medical Sciences, Zand St., 71 32326645, Shiraz, Iran
| | - Omidreza Azh
- Department of Pediatric Surgery, Nemazee Hospital, Shiraz University of Medical Sciences, Zand St., 71 32326645, Shiraz, Iran
| | - Ali Tadayon
- Department of Pediatric Surgery, Nemazee Hospital, Shiraz University of Medical Sciences, Zand St., 71 32326645, Shiraz, Iran
| | - Alireza Sherafat
- School of Medicine, University of Central Lancashire, Preston, England
| | - Amir Arsalan Yaghoobi
- Department of Pediatric Surgery, Nemazee Hospital, Shiraz University of Medical Sciences, Zand St., 71 32326645, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Zand St., 71 32326645, Shiraz, Iran
| | - Mohammad Ali Ashraf
- Department of Pediatric Surgery, Nemazee Hospital, Shiraz University of Medical Sciences, Zand St., 71 32326645, Shiraz, Iran.
- Student Research Committee, Shiraz University of Medical Sciences, Zand St., 71 32326645, Shiraz, Iran.
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20
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Liu T, Wang RX, Han J, Qiu YL, Borchers CH, Ling V, Wang JS. Changes in plasma bile acid profiles after partial internal biliary diversion in PFIC2 patients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:185. [PMID: 32309332 PMCID: PMC7154393 DOI: 10.21037/atm.2020.01.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background We ask if plasma bile acid profiles can be used to monitor the effectiveness of partial internal biliary diversion (PIBD) for treating uncontrolled cholestasis in progressive familial intrahepatic cholestasis type 2 (PFIC2) patients. Methods Plasma bile acids were profiled in 3 cases of ATP-binding cassette, sub-family B member 11 (ABCB11)-mutated PFIC2 children before and after PIBD compared to healthy controls and 8 PFIC2 patients. The quantitation of bile acids was performed by reversed-phase ultrahigh-performance liquid chromatography/multiple-reaction monitoring-mass spectrometry (UPLC/MRM-MS) with negative ion detection. Results Before PIBD, all three patients presented with >50-fold higher levels of total plasma bile acids, 2-7 folds higher ratios of taurine: glycine conjugated primary bile acids, and unchanged secondary bile acids levels compared to healthy controls. After PIBD, only one of the three patients (P3) showed relief of cholestasis. The bile acid profiles of the two nonresponding patients showed little change while that of the responding patient showed a 5-fold reduction in total plasma primary bile acids, a reduced taurine: glycine conjugate ratio, and an unexpected 26- and 12-fold increase in secondary bile acids DCA and LCA respectively. One year later, the responder suffered a recurrence of cholestasis, and the bile acid profile shifted back to a more pre-PIBD-like profile. Conclusions Plasma bile acid profiles may potentially be useful as sensitive biomarkers for monitoring the clinical course of PIBD patients. Relief of cholestasis after PIBD appears to be associated with significantly increased circulating toxic secondary bile acids and this may limit the utility of PIBD in PFIC2 patients in the long run.
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Affiliation(s)
- Teng Liu
- Department of Pediatrics, Fudan University Shanghai Medical College, The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, Shanghai 201102, China.,BC Cancer Agency, Vancouver, British Columbia, Canada.,University of Victoria-Genome BC Proteomics Centre, University of Victoria, Victoria, British Columbia, Canada
| | - Ren-Xue Wang
- BC Cancer Agency, Vancouver, British Columbia, Canada
| | - Jun Han
- University of Victoria-Genome BC Proteomics Centre, University of Victoria, Victoria, British Columbia, Canada.,Division of Medical Sciences, University of Victoria, Victoria, BC, Canada
| | - Yi-Ling Qiu
- Department of Pediatrics, Fudan University Shanghai Medical College, The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Christoph H Borchers
- University of Victoria-Genome BC Proteomics Centre, University of Victoria, Victoria, British Columbia, Canada.,Department of Biochemistry and Microbiology, University of Victoria, Victoria, British Columbia, Canada.,Gerald Bronfman Department of Oncology and Proteomics Centre, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Segal Cancer Centre, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Department of Data Intensive Science and Engineering, Skolkovo Institute of Science and Technology, Skolkovo Innovation Center, Moscow, Russia
| | - Victor Ling
- BC Cancer Agency, Vancouver, British Columbia, Canada
| | - Jian-She Wang
- Department of Pediatrics, Fudan University Shanghai Medical College, The Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, Shanghai 201102, China
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Chen L, Xiao H, Ren XH, Li L. Long-term outcomes after cholecystocolostomy for progressive familial intrahepatic cholestasis. Hepatol Res 2018; 48:1163-1171. [PMID: 29934967 DOI: 10.1111/hepr.13222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/26/2018] [Accepted: 06/13/2018] [Indexed: 12/12/2022]
Abstract
AIM To evaluate the long-term efficacy of cholecystocolostomy surgery for progressive familial intrahepatic cholestasis (PFIC). METHODS From August 2003 to November 2014, 34 clinically diagnosed children, including 11 with familial intrahepatic cholestasis-1 (FIC1), 13 with bile salt export pump (BSEP) disease, five with low γ-glutamyl transpeptidase (GGT) disease (levels <100 U/L), and five with multidrug resistance class III (MDR3) disease with high GGT (>100 U/L), were identified in our center. Data were collected retrospectively from individuals who collectively had 36 surgical operations and two orthotopic liver transplantations (OLT). RESULTS Serum total bilirubin (0 = 163.54 ± 106.02, 36 months = 23.38 ± 17.66 μmol/L) and bile acid (0 = 325.83 ± 153.09, 36 months = 48.36 ± 79.71 μmol/L) decreased after cholecystocolostomy in PFIC patients (P < 0.001). All patients experienced decreased severity of pruritus (88.2% vs. 16.1%, P < 0.001) and a greater freedom from growth retardation after cholecystocolostomy (-3.35 vs. -1.03, P < 0.001). Defecation frequency increased in PFIC patients after cholecystocolostomy (P = 0.002). Four patients (three with FIC1 and one with BSEP) experienced recurrence of cholestasis and two underwent reoperation. Two BSEP patients underwent OLT. One patient with BSEP and one patient with MDR3 died due to severe diarrhea and dehydration; one BSEP patient died of intractable constipation. CONCLUSIONS This is the first long-term, large-scale analysis of cholecystocolostomy approaches for PFIC. Approaches single and well tolerated, and generally result in improvement of pruritus and cholestasis.
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Affiliation(s)
- Long Chen
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Hui Xiao
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiang-Hai Ren
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Long Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, China
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22
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Abstract
Progressive familial intrahepatic cholestasis (PFIC) is a group of autosomal recessive cholestatic liver diseases which are subgrouped according to the genetic defect, clinical presentation, laboratory findings and liver histology. Progressive liver fibrosis, cirrhosis, and end stage liver disease (ESLD) may eventually develop. PFIC was first described in Amish descendants of Jacob Byler, therefore it was originally called Byler disease. But it can be seen anywhere on the globe. This review summarizes the main features of the subtypes of the disease and discusses the current available diagnosis, conservative and surgical therapeutic options.
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Affiliation(s)
- Mithat Gunaydin
- Avicenna Hospital, Department of Pediatric Surgery, Istanbul, Turkey,
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23
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Sharma A, Poddar U, Agnihotry S, Phadke SR, Yachha SK, Aggarwal R. Spectrum of genomic variations in Indian patients with progressive familial intrahepatic cholestasis. BMC Gastroenterol 2018; 18:107. [PMID: 29973134 PMCID: PMC6032793 DOI: 10.1186/s12876-018-0835-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/26/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Progressive familial intrahepatic cholestasis (PFIC) is caused by variations in ATP8B1, ABCB11 or ABCB4 genes. Data on genetic variations in Indian patients with PFIC are lacking. METHODS Coding and splice regions of the three genes were sequenced in unrelated Indian children with PFIC phenotype. The variations identified were looked for in parents, 30 healthy persons and several variation databases, and their effect was assessed in-silico. RESULTS Among 25 children (aged 1-144 months), nine (36%) had unique major genomic variations (ATP8B1: 4, ABCB11: 3 and ABCB4: 2). Seven had homozygous variations, which were assessed as 'pathogenic' or 'likely pathogenic'. These included: (i) four amino acid substitutions (ATP8B1: c.1660G > A/p.Asp554Asn and c.2941G > A/p.Glu981Lys; ABCB11: c.548 T > C/p.Met183Thr; ABCB4: c.431G > A/p.Arg144Gln); (ii) one 3-nucleotide deletion causing an amino acid deletion (ATP8B1: c.1587_1589delCTT/p.Phe529del); (iii) one single-nucleotide deletion leading to frame-shift and premature termination (ABCB11: c.1360delG/p.Val454Ter); and (iv) a complex inversion of 4 nucleotides with a single-nucleotide insertion leading to frame-shift and premature termination (ATP8B1: c.[589_592inv;592_593insA]/p.Gly197LeufsTer10). Two variations were found in heterozygous form: (i) a splice-site variation likely to cause abnormal splicing (ABCB11: c.784 + 1G > C), and (ii) a nucleotide substitution that created a premature stop codon (ABCB4: c.475C > T/p.Arg159Ter); these were considered as variations of uncertain significance. Three of the nine variations were novel. CONCLUSIONS Nine major genomic variations, including three novel ones, were identified in nearly one-third of Indian children with PFIC. No variation was identified in nearly two-thirds of patients, who may have been related to variations in promoter or intronic regions of the three PFIC genes, or in other bile-salt transport genes.
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Affiliation(s)
- Anjali Sharma
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014 India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014 India
| | - Shikha Agnihotry
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014 India
| | - Shubha R. Phadke
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014 India
| | - Surender K. Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014 India
| | - Rakesh Aggarwal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014 India
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Flores CD, Yu YR, Miloh TA, Goss J, Brandt ML. Surgical outcomes in Alagille syndrome and PFIC: A single institution's 20-year experience. J Pediatr Surg 2018; 53:976-979. [PMID: 29729773 DOI: 10.1016/j.jpedsurg.2018.02.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 02/01/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Alagille Syndrome (AGS) and Progressive Familial Intrahepatic Cholestasis (PFIC) are rare pediatric biliary disorders that lead to progressive liver disease. This study reviews our experience with the surgical management of these disorders over the last 20years. METHODS We retrospectively reviewed the records of children diagnosed with AGS or PFIC from January 1996 to December 2016. Data collected included demographics, surgical intervention (liver transplant or biliary diversion), and complications. RESULTS Of 37 patients identified with these disorders, 17 patients (8 AGS,9 PFIC) underwent surgical intervention. Mean postsurgical follow-up was 6.9±4.7years. Liver transplantation was the most common procedure (n=14). Two patients who were initially thought to have biliary atresia underwent hepatoportoenterostomy, but were subsequently shown to have Alagille syndrome. Biliary diversion procedures were performed in 3 patients (external n=1, internal n=2). PFIC patients tended to be older at the time of liver transplant compared to AGS (4.3±3.9years vs. 2.4±1.1years, p=0.25). The AGS patient with external diversion had resolution of symptoms and no complications (follow-up: 12.5years). Both PFIC patients with internal diversion (conduit between gallbladder and transverse colon) had resolution of pruritus and no progression of liver disease (follow-up: 3.8 and 4.5years). CONCLUSIONS AGS and PFIC are rare biliary disorders in children which result in pruritus and progressive liver failure. Three patients in this series (8%) benefited from biliary diversion for control of pruritus and have not to date required transplantation for progressive liver disease. 38% underwent transplantation owing to pruritus and severe liver dysfunction. LEVEL OF EVIDENCE 2b.
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Affiliation(s)
- Celia D Flores
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Yangyang R Yu
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Tamir A Miloh
- Section of Hepatology and Liver Transplant Medicine, Department of Pediatrics, Texas Children's Hospital, , Houston, TX, United States
| | - John Goss
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Mary L Brandt
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.
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25
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Erginel B, Soysal FG, Durmaz O, Celik A, Salman T. Long-term outcomes of six patients after partial internal biliary diversion for progressive familial intrahepatic cholestasis. J Pediatr Surg 2018; 53:468-471. [PMID: 29174177 DOI: 10.1016/j.jpedsurg.2017.10.055] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 10/19/2017] [Accepted: 10/22/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Partial internal biliary diversion (PIBD) is an alternative approach for the treatment of devastating pruritus in patients with progressive familial intrahepatic cholestasis (PFIC). In these patients quality of life can be improved and progression of liver disease can be delayed while waiting for liver transplantation. The aim of our study was to evaluate six patients with PFIC who have undergone PIBD in long-term follow-up. METHODS Retrospective review of the records of six patients who underwent PIBD for PFIC between 2008 and 2010 was conducted to evaluate age, growth, clinical and laboratory studies for long-term outcome. RESULTS Serum postoperative bile acid levels were reduced from a mean 340.1μmol/L (range 851-105) preoperatively to a mean of 96.3μmol/L at postoperative fifth year. The difference between pre- and postoperative bile acid levels was statistically significant (p=0.018). AST decreased from 79.1U/L (range 43-150U/L) to 64.6U/L (range 18-172U/L), ALT decreased from 102.8U/L (range 35-270U/L) to 84.6U/L and total bilirubin decreased from 2.9μmol/L (range 0.35-6.4μmol/L) to 1.53μmol/L (range 0.3-2.4). Again, the decrease in total bilirubin levels was significant (p=0.043). Pruritus was diminished from a mean of +4 (range 4-4) preoperatively to a mean of +2 (4-0). One patient who underwent liver transplantation owing to relapsing pruritus died from postoperative sepsis in the early postoperative period at the fifth year after PBID. Five symptom-free patients have not required liver transplantation at a mean period of 6.1±0.83years (5.1-7.0years) follow-up. CONCLUSION PBID is an effective surgical procedure in the long-term and can delay the need for liver transplantation in children with PFIC by reducing jaundice and pruritus.
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Affiliation(s)
- Basak Erginel
- Istanbul University, Istanbul Medical Faculty, Department of Pediatric Surgery.
| | - Feryal Gun Soysal
- Istanbul University, Istanbul Medical Faculty, Department of Pediatric Surgery
| | - Ozlem Durmaz
- Istanbul University, Istanbul Medical Faculty, Department of Pediatric Gastroenterology
| | - Alaattin Celik
- Istanbul University, Istanbul Medical Faculty, Department of Pediatric Surgery
| | - Tansu Salman
- Istanbul University, Istanbul Medical Faculty, Department of Pediatric Surgery
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Xiang D, He J, Wang H, Xiong F, Cheng H, Ai J, Shan R, Wan R, Zhang L, Shi J. Liver transplantation for decompensated liver cirrhosis caused by progressive familial intrahepatic cholestasis type 3: A case report. Medicine (Baltimore) 2017; 96:e9158. [PMID: 29390323 PMCID: PMC5815735 DOI: 10.1097/md.0000000000009158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
RATIONALE Progressive familial intrahepatic cholestasis (PFIC) type 3, characterized by high gamma glutamyl transferase (GGT), is an autosomal recessive genetic disease. It often occurs in patients' first years of age. However, high GGT type PFIC is still rare. PATIENT CONCERNS The present study reports a case of liver transplantation for decompensated liver cirrhosis caused by PFIC type 3. An 18-year-old male presented with a history of abdominal distension and jaundice for 2 months. He had abdominal tenderness but no rebounding pain. Moreover, his dullness was felt over the liver and the spleen was palpable 8 cm below the ribs. DIAGNOSES Computed tomography and magnetic resonance cholangiopancreato graphy of the upper abdomen revealed cirrhosis, portal hypertension, collateral circulation formation, large spleen, and ascites. Blood biochemistry showed high alanine transaminase, aspartate transaminase, and GGT. The diagnosis of decompensated liver cirrhosis caused by PFIC-3 was finally confirmed by plasma gene detecting. INTERVENTIONS The patient received an open surgery named allogeneic liver transplantation after successful matching of immune types between the recipient and donor. Peritoneal puncture and catheter drainage under B-ultrasound was performed when an encapsulated effusion between the liver and stomach arose. OUTCOMES The patient was discharged without specific discomfort and was almost free of fluid accumulation 51 days after the surgery. At the 6-month follow-up, he had no discomfort and the blood routine, liver functions showed no abnormalities. LESSONS We found a new mutant fragment of ABCB4 gene in the process of diagnosis. Liver transplantation remains the most definitive treatment for PFIC. Current medical therapies and surgical interventions such as biliary diversion have potentially created a synergistic outcome.
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Affiliation(s)
- Deng Xiang
- Department of General Surgery, The First Affiliated Hospital of Nanchang University
| | - Jiannan He
- Department of General Surgery, The First Affiliated Hospital of Nanchang University
| | - Hongmei Wang
- Department of General Surgery, The First Affiliated Hospital of Nanchang University
| | - Fangfang Xiong
- Basic Nursing Teaching and Research Office, Nanchang City Health School
| | - Hao Cheng
- Department of General Surgery, The First Affiliated Hospital of Nanchang University
| | - Junhua Ai
- Department of General Surgery, The First Affiliated Hospital of Nanchang University
| | - Renfeng Shan
- Department of General Surgery, The First Affiliated Hospital of Nanchang University
| | - Renhua Wan
- Department of General Surgery, The First Affiliated Hospital of Nanchang University
| | - Lunli Zhang
- Department of Infectious Disease, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jun Shi
- Department of General Surgery, The First Affiliated Hospital of Nanchang University
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Wang KS, Tiao G, Bass LM, Hertel PM, Mogul D, Kerkar N, Clifton M, Azen C, Bull L, Rosenthal P, Stewart D, Superina R, Arnon R, Bozic M, Brandt ML, Dillon PA, Fecteau A, Iyer K, Kamath B, Karpen S, Karrer F, Loomes KM, Mack C, Mattei P, Miethke A, Soltys K, Turmelle YP, West K, Zagory J, Goodhue C, Shneider BL. Analysis of surgical interruption of the enterohepatic circulation as a treatment for pediatric cholestasis. Hepatology 2017; 65:1645-1654. [PMID: 28027587 PMCID: PMC5397365 DOI: 10.1002/hep.29019] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 11/21/2016] [Accepted: 12/20/2016] [Indexed: 12/12/2022]
Abstract
UNLABELLED To evaluate the efficacy of nontransplant surgery for pediatric cholestasis, 58 clinically diagnosed children, including 20 with Alagille syndrome (ALGS), 16 with familial intrahepatic cholestasis-1 (FIC1), 18 with bile salt export pump (BSEP) disease, and 4 others with low γ-glutamyl transpeptidase disease (levels <100 U/L), were identified across 14 Childhood Liver Disease Research Network (ChiLDReN) centers. Data were collected retrospectively from individuals who collectively had 39 partial external biliary diversions (PEBDs), 11 ileal exclusions (IEs), and seven gallbladder-to-colon (GBC) diversions. Serum total bilirubin decreased after PEBD in FIC1 (8.1 ± 4.0 vs. 2.9 ± 4.1 mg/dL, preoperatively vs. 12-24 months postoperatively, respectively; P = 0.02), but not in ALGS or BSEP. Total serum cholesterol decreased after PEBD in ALGS patients (695 ± 465 vs. 457 ± 319 mg/dL, preoperatively vs. 12-24 months postoperatively, respectively; P = 0.0001). Alanine aminotransferase levels increased in ALGS after PEBD (182 ± 70 vs. 260 ± 73 IU/L, preoperatively vs. 24 months; P = 0.03), but not in FIC1 or BSEP. ALGS, FIC1, and BSEP patients experienced less severely scored pruritus after PEBD (ALGS, 100% vs. 9% severe; FIC1, 64% vs. 10%; BSEP, 50% vs. 20%, preoperatively vs. >24 months postoperatively, respectively; P < 0.001). ALGS patients experienced a trend toward greater freedom from xanthomata after PEBD. There was a trend toward decreased pruritus in FIC1 after IE and GBC. Vitamin K supplementation increased in ALGS after PEBD (33% vs. 77%; P = 0.03). Overall, there were 15 major complications after surgery. Twelve patients (3 ALGS, 3 FIC1, and 6 BSEP) subsequently underwent liver transplantation. CONCLUSION This was a multicenter analysis of nontransplant surgical approaches to intrahepatic cholestasis. Approaches vary, are well tolerated, and generally, although not uniformly, result in improvement of pruritus and cholestasis. (Hepatology 2017;65:1645-1654).
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Affiliation(s)
| | - Greg Tiao
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Lee M. Bass
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | | | | | - Nanda Kerkar
- Children’s Hospital Los Angeles, Los Angeles, CA
| | | | - Colleen Azen
- Children’s Hospital Los Angeles, Los Angeles, CA
| | - Laura Bull
- University of California, San Francisco, CA
| | | | | | | | | | - Molly Bozic
- Riley Hospital for Children, Indianapolis, IN
| | | | | | | | | | | | - Saul Karpen
- Children’s Healthcare of Atlanta, Atlanta, GA
| | | | | | - Cara Mack
- Children’s Hospital Colorado, Aurora, CO
| | - Peter Mattei
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Kyle Soltys
- Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | | | - Karen West
- Riley Hospital for Children, Indianapolis, IN
| | | | - Cat Goodhue
- Children’s Hospital Los Angeles, Los Angeles, CA
| | - Benjamin L. Shneider
- Texas Children’s Hospital, Houston, TX,Children’s Hospital of Pittsburgh, Pittsburgh, PA
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28
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van der Woerd WL, Houwen RHJ, van de Graaf SFJ. Current and future therapies for inherited cholestatic liver diseases. World J Gastroenterol 2017; 23:763-775. [PMID: 28223721 PMCID: PMC5296193 DOI: 10.3748/wjg.v23.i5.763] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 11/16/2016] [Accepted: 01/11/2017] [Indexed: 02/06/2023] Open
Abstract
Familial intrahepatic cholestasis (FIC) comprises a group of rare cholestatic liver diseases associated with canalicular transport defects resulting predominantly from mutations in ATP8B1, ABCB11 and ABCB4. Phenotypes range from benign recurrent intrahepatic cholestasis (BRIC), associated with recurrent cholestatic attacks, to progressive FIC (PFIC). Patients often suffer from severe pruritus and eventually progressive cholestasis results in liver failure. Currently, first-line treatment includes ursodeoxycholic acid in patients with ABCB4 deficiency (PFIC3) and partial biliary diversion in patients with ATP8B1 or ABCB11 deficiency (PFIC1 and PFIC2). When treatment fails, liver transplantation is needed which is associated with complications like rejection, post-transplant hepatic steatosis and recurrence of disease. Therefore, the need for more and better therapies for this group of chronic diseases remains. Here, we discuss new symptomatic treatment options like total biliary diversion, pharmacological diversion of bile acids and hepatocyte transplantation. Furthermore, we focus on emerging mutation-targeted therapeutic strategies, providing an outlook for future personalized treatment for inherited cholestatic liver diseases.
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Kubitz R, Dröge C, Kluge S, Stindt J, Stross C, Häussinger D, Flechtenmacher C, Wenning D, Teufel U, Schmitt CP, Engelmann G. High affinity anti-BSEP antibodies after liver transplantation for PFIC-2 - Successful treatment with immunoadsorption and B-cell depletion. Pediatr Transplant 2016; 20:987-993. [PMID: 27368585 DOI: 10.1111/petr.12751] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2016] [Indexed: 01/22/2023]
Abstract
PFIC due to BSEP mutations (PFIC type 2) often necessitates OLT. It has recently been recognized that some PFIC-2 patients develop phenotypic disease recurrence post-OLT due to the appearance of anti-BSEP antibodies. Here, we describe a boy who became cholestatic four yr after OLT during modification of immunosuppression. Canalicular antibody deposits were detected in biopsies of the transplant and antibodies specifically reacting with BSEP were identified at high titers in his serum. These antibodies bound extracellular epitopes of BSEP and inhibited BS transport and were assumed to cause disease recurrence. Consequently, anti-BSEP antibody depletion was pursued by IA and B-cell depletion by anti-CD20 antibodies (rituximab) along with a switch of immunosuppression. This treatment resulted in prolonged relief of symptoms. Depletion of pathogenic anti-BSEP antibodies causing AIBD after OLT in PFIC-2 patients should be considered as a central therapeutic goal.
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Affiliation(s)
- Ralf Kubitz
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Carola Dröge
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Stefanie Kluge
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jan Stindt
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Claudia Stross
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Dieter Häussinger
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | | | - Daniel Wenning
- Department of General Paediatrics, Centre for Paediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Ulrike Teufel
- Department of General Paediatrics, Centre for Paediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Claus Peter Schmitt
- Department of General Paediatrics, Centre for Paediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
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Agarwal S, Lal BB, Rawat D, Rastogi A, Bharathy KG, Alam S. Progressive Familial Intrahepatic Cholestasis (PFIC) in Indian Children: Clinical Spectrum and Outcome. J Clin Exp Hepatol 2016; 6:203-208. [PMID: 27746616 PMCID: PMC5052402 DOI: 10.1016/j.jceh.2016.05.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/06/2016] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To study the clinical and laboratory profile of children with progressive familial intrahepatic cholestasis (PFIC) and evaluate their outcome. METHODS The study is a retrospective review of all cases diagnosed with PFIC between January 2011 and July 2015. All children underwent histopathological examination and immunostaining. Management was done as per institute's protocol. RESULTS There were a total of 24 PFIC cases (PFIC 1-2, PFIC 2-19, PFIC 3-3). Eleven presented as neonatal cholestasis, whereas 13 others presented after 6 months of life. Median age of presentation in PFIC 2 was 5.5 months with a time lag of 13 months in diagnosis. PFIC 1 and 2 presented in infancy, whereas PFIC 3 presented late. Familial clustering was seen in 12 of 24 cases. Pruritus resolved with medical management in two-thirds of cases, 3 cases required biliary diversion (BD) with dramatic improvement. One child improved after liver transplantation. CONCLUSIONS PFIC accounts for 8% of neonatal cholestasis and 34% of cholestasis in older children with PFIC 2 being the commonest subtype. Medical therapy is successful in majority. Partial internal BD should be offered to non-cirrhotic low gamma glutamyl transferase PFIC with intractable pruritus. Progression to cirrhosis may be prevented or delayed by early diagnosis and timely intervention.
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Key Words
- BD, biliary diversion
- BSEP, bile salt export pump
- DDLT, deceased donor liver transplantation
- ESLD, end stage liver disease
- GGT, gamma glutamyl transferase
- HE, hepatic encephalopathy
- ICP, intrahepatic cholestasis of pregnancy
- LFT, liver functions test
- LT, liver transplantation
- MDR3, multi drug resistant protein 3
- NCS, neonatal cholestasis syndrome
- PEBD, partial external biliary diversion
- PFIC, progressive familial intrahepatic cholestasis
- PIBD, partial internal biliary diversion
- UDCA, ursodeoxycholic acid
- biliary diversion
- gamma-glutamyl transferase
- immunostaining
- neonatal cholestasis
- pruritus
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Affiliation(s)
- Sajan Agarwal
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Bikrant Bihari Lal
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Dinesh Rawat
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Archana Rastogi
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kishore G.S. Bharathy
- Department of HPB Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India,Address for correspondence: Seema Alam, Professor & Head, Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India. Tel.: +91 9540951008.Department of Pediatric Hepatology, Institute of Liver and Biliary SciencesNew DelhiIndia
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Mehl A, Bohorquez H, Serrano MS, Galliano G, Reichman TW. Liver transplantation and the management of progressive familial intrahepatic cholestasis in children. World J Transplant 2016; 6:278-290. [PMID: 27358773 PMCID: PMC4919732 DOI: 10.5500/wjt.v6.i2.278] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/24/2016] [Accepted: 03/14/2016] [Indexed: 02/05/2023] Open
Abstract
Progressive familial intrahepatic cholestasis (PFIC) is a constellation of inherited disorders that result in the impairment of bile flow through the liver that predominantly affects children. The accumulation of bile results in progressive liver damage, and if left untreated leads to end stage liver disease and death. Patients often present with worsening jaundice and pruritis within the first few years of life. Many of these patients will progress to end stage liver disease and require liver transplantation. The role and timing of liver transplantation still remains debated especially in the management of PFIC1. In those patients who are appropriately selected, liver transplantation offers an excellent survival benefit. Appropriate timing and selection of patients for liver transplantation will be discussed, and the short and long term management of patients post liver transplantation will also be described.
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32
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Gunaydin M, Tander B, Demirel D, Caltepe G, Kalayci AG, Eren E, Bicakcı U, Rizalar R, Ariturk E, Bernay F. Different techniques for biliary diversion in progressive familial intrahepatic cholestasis. J Pediatr Surg 2016; 51:386-9. [PMID: 26382286 DOI: 10.1016/j.jpedsurg.2015.08.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 08/11/2015] [Accepted: 08/15/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Progressive familial intrahepatic cholestasis (PFIC) is a cholestatic liver disease of childhood. Pruritus resulting from increased bile salts in serum might not respond to medical treatment, and internal or external biliary drainage methods have been described. In this study, we aimed to evaluate different internal drainage techniques in patients with PFIC. PATIENTS AND METHODS Between 2009 and 2014, seven children (4 male, 3 female, 3months-5years old), (median 2years of age) with PFIC were evaluated. The patients were reviewed according to age, gender, complaints, surgical technique, laboratory findings and outcome. In each two patients, cholecystoileocolonic anastomosis, cholecystojejunocolonic anastomosis and cholecystocolostomy were performed. Cholecysto-appendico-colonic anastomosis was the technique used in one patient. RESULTS Jaundice and excessive pruritus were the main complaints. One of the patients with cholecystoileocolonic anastomosis died of comorbid pathologies (cirrhosis, adhesive obstruction and severe sepsis). Temporary rectal bleeding was observed in all the patients postoperatively. Regardless of the surgical technique, pruritus was dramatically decreased in all the patients in the postoperative period. CONCLUSION Regardless of the technique, internal biliary diversion methods are beneficial for the relief of pruritus in PFIC patients. Selection of the surgical method might vary depending on the surgeon's preference and the surgical anatomy of the gastrointestinal system of the patient.
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Affiliation(s)
- Mithat Gunaydin
- Department of Pediatric Surgery, Ondokuz Mayis University, Samsun, Turkey.
| | - Burak Tander
- Department of Pediatric Surgery, Ondokuz Mayis University, Samsun, Turkey
| | - Dilek Demirel
- Department of Pediatric Surgery, Ondokuz Mayis University, Samsun, Turkey
| | - Gonul Caltepe
- Department of Pediatric Gastroenterology, Ondokuz Mayis University, Samsun, Turkey
| | - Ayhan Gazi Kalayci
- Department of Pediatric Gastroenterology, Ondokuz Mayis University, Samsun, Turkey
| | - Esra Eren
- Department of Pediatric Gastroenterology, Ondokuz Mayis University, Samsun, Turkey
| | - Unal Bicakcı
- Department of Pediatric Surgery, Ondokuz Mayis University, Samsun, Turkey
| | - Riza Rizalar
- Department of Pediatric Surgery, Ondokuz Mayis University, Samsun, Turkey
| | - Ender Ariturk
- Department of Pediatric Surgery, Ondokuz Mayis University, Samsun, Turkey
| | - Ferit Bernay
- Department of Pediatric Surgery, Ondokuz Mayis University, Samsun, Turkey
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van der Woerd WL, Kokke FT, van der Zee DC, Houwen RH. Total biliary diversion as a treatment option for patients with progressive familial intrahepatic cholestasis and Alagille syndrome. J Pediatr Surg 2015; 50:1846-9. [PMID: 26319776 DOI: 10.1016/j.jpedsurg.2015.07.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/28/2015] [Accepted: 07/06/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND Progressive familial intrahepatic cholestasis (PFIC) with low gamma-glutamyl transpeptidase (GGT) and Alagille syndrome are associated with persistent cholestasis and severe pruritus. Various types of biliary diversion have been used to reduce this pruritus and prevent liver dysfunction. We report our experience concerning the efficacy and safety of total biliary diversion (TBD) as an additional treatment option. METHODS TBD was performed in four PFIC patients and one patient with Alagille syndrome, and was accomplished by anastomosing a jejunal segment to the choledochal duct terminating as an end stoma, or by disconnecting the choledochal duct after previous cholecystojejunocutaneostomy. RESULTS TBD resulted in a marked improvement of symptoms and biochemical parameters in all PFIC patients. Despite relief of pruritus, cholestasis persisted in the Alagille patient. During 5-15years of follow-up, no clinical signs of fat malabsorption such as diarrhea or weight loss were encountered. However, to maintain adequate levels of fat-soluble vitamins, especially of vitamin K, substantial supplementation was necessary. CONCLUSIONS Total biliary diversion can be a useful surgical treatment option for patients with low-GGT PFIC and possibly also Alagille syndrome, when partial biliary diversion is insufficient. It can be performed without inducing clinical signs of fat malabsorption although individualized supplementation of fat-soluble vitamins with careful monitoring is warranted.
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Affiliation(s)
- Wendy L van der Woerd
- Department of Pediatric Gastroenterology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Freddy T Kokke
- Department of Pediatric Gastroenterology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - David C van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Roderick H Houwen
- Department of Pediatric Gastroenterology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
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