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Jeyaraj R, Maher ER, Kelly D. Paediatric research sets new standards for therapy in paediatric and adult cholestasis. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:75-84. [PMID: 38006895 DOI: 10.1016/s2352-4642(23)00259-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 11/27/2023]
Abstract
Children with Alagille syndrome and progressive familial intrahepatic cholestasis (PFIC) experience debilitating pruritus, for which there have been few effective treatment options. In the past 2 years, the ileal bile acid transporter (IBAT) inhibitors maralixibat and odevixibat have been approved for the management of cholestatic pruritus in these individuals, representing an important step forward in improving their quality of life. Emerging data suggest these drugs might also improve event-free survival, therefore potentially altering the typical disease course currently seen in these disorders. This Review will discuss how genetic advances have clarified the molecular basis of cholestatic disorders, facilitating the development of new therapeutic options that have only been evaluated in children. We focus specifically on the newly licensed IBAT inhibitors for patients with Alagille syndrome and PFIC and explore the next steps for these drugs in relation to other paediatric and adult cholestatic disorders, recognising that they have the potential to benefit a wider group of patients with gastrointestinal and liver disease.
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Affiliation(s)
- Rebecca Jeyaraj
- University College London Great Ormond Street Institute of Child Health, London, UK
| | - Eamonn R Maher
- Department of Medical Genetics, University of Cambridge, Cambridge, UK
| | - Deirdre Kelly
- The Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, UK; University of Birmingham, Birmingham, UK.
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Gamma-Glutamyl Transferase: A Friend against Cholestatic Itch? A Retrospective Observational Data Analysis in Patients with Extrahepatic Cholestasis. Int J Hepatol 2023; 2023:2903171. [PMID: 36816714 PMCID: PMC9931488 DOI: 10.1155/2023/2903171] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/19/2023] [Accepted: 01/28/2023] [Indexed: 02/24/2023] Open
Abstract
Methods We included 235 patients with chronic extrahepatic cholestasis due to pancreatic cancer, cholangiocarcinoma, or papillary carcinoma. Results GGT was significantly higher in patients without pruritus (median 967, IQR 587-1571) compared to patients with pruritus (median 561 IQR 266-1084 IU/l) (p < 0.01). In contrast, median alkaline phosphatase (AP) was 491 U/L (IQR; 353-684) in patients with pruritus and was not significantly different from 518 U/L (IQR; 353-726) in patients without pruritus (p = 0.524). Direct bilirubin was significantly higher in patients with pruritus compared to patients without pruritus (168 μmol/L (IQR; 95-256) vs. 120 μmol/L (IQR; 56.75-185.5)) (p < 0.01). After correcting for the extent of cholestasis via direct bilirubin, the negative association between GGT and pruritus remained significant and became stronger (p < 0.001). Conclusion Serum GGT activity is inversely associated with the presence of cholestatic itch in patients with chronic extrahepatic cholestasis.
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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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Henkel SAF, Salgado CM, Reyes-Mugica M, Soltys KA, Strauss K, Mazariegos GV, Squires RH, McKiernan PJ, Zhang X, Squires JE. Long-term liver transplant outcomes for progressive familial intrahepatic cholestasis type 1: The Pittsburgh experience. Pediatr Transplant 2021; 25:e14108. [PMID: 34339082 DOI: 10.1111/petr.14108] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/26/2021] [Accepted: 07/23/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Progressive familial intrahepatic cholestasis type 1 (PFIC1) arises from biallelic variants in the ATP8B1 gene that annul FIC1 activity, resulting in progressive liver disease. Liver transplant (LT) is indicated in refractory disease; however, post-LT complications including worsening diarrhea and steatohepatitis progressing to fibrosis with graft loss have been reported. We aim to describe long-term outcomes of PFIC1 LT recipients at our center, focusing on the histological changes of the allografts. METHODS We assessed 7 PFIC1 patients post-LT at the Children's Hospital of Pittsburgh (CHP). All pre-transplant, explant, and sequential post-transplant pathology samples were reviewed. Continuous data are presented as the mean ± SD. We compared the pre- and post-transplant height and weight z-scores using Wilcoxon signed-rank test. RESULTS Seven (29% male) patients with PFIC1 received a LT (n = 6) or had post-LT care (n = 1) at CHP. Six had confirmed or suspected identical genetic. At a mean follow-up of 10.9 years, both patient survival and graft survival were 100%. Diarrhea persisted (n = 3) or newly developed (n = 4) in all patients after LT contributing to ongoing growth failure, with mean z-scores -2.63 (weight) and -2.98 (height) at follow-up. Histologically, allograft steatosis was common but was not accompanied by significant inflammation, ballooning, or fibrosis. CONCLUSION We show that extrahepatic disease persists and near-universal allograft steatosis occurs. However, at a mean follow-up period of over 10 years, no patients developed steatohepatitis or significant fibrosis, and both patient survival and graft survival are excellent.
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Affiliation(s)
- Sarah A F Henkel
- Department of Pediatric Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Claudia M Salgado
- Department of Pathology, University of Pittsburgh, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Miguel Reyes-Mugica
- Department of Pathology, University of Pittsburgh, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Kyle A Soltys
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Kevin Strauss
- Clinic for Special Children, Strasburg, PA, USA.,Department of Pediatrics, Penn Medicine-Lancaster General Hospital, Lancaster, PA, USA
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Robert H Squires
- Department of Pediatric Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J McKiernan
- Department of Pediatric Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Xingyu Zhang
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James E Squires
- Department of Pediatric Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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Felzen A, Verkade HJ. The spectrum of Progressive Familial Intrahepatic Cholestasis diseases: Update on pathophysiology and emerging treatments. Eur J Med Genet 2021; 64:104317. [PMID: 34478903 DOI: 10.1016/j.ejmg.2021.104317] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/11/2021] [Accepted: 08/22/2021] [Indexed: 02/07/2023]
Abstract
The Progressive Familial Intrahepatic Cholestasis (PFIC) disease spectrum encompasses a variety of genetic diseases that affect the bile production and the secretion of bile acids. Typically, the first presentation of these diseases is in early childhood, frequently followed by a severe course necessitating liver transplantation before adulthood. Except for transplantation, treatment modalities have been rather limited and frequently only aim at the symptoms of cholestasis, such as cholestatic pruritus. In recent years, progress has been made in understanding the pathophysiology of these diseases and new treatment modalities have been emerging. Herewith we summarize the latest developments in the field and formulate the current key questions and opportunities for further progress.
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Affiliation(s)
- Antonia Felzen
- Pediatric Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Henkjan J Verkade
- Pediatric Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, the Netherlands.
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