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Tang M, Xiong L, Cai J, Fu J, Liu H, Ye Y, Yang L, Xing S, Yang X. Intrahepatic cholestasis of pregnancy: insights into pathogenesis and advances in omics studies. Hepatol Int 2024; 18:50-62. [PMID: 37957532 DOI: 10.1007/s12072-023-10604-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 09/28/2023] [Indexed: 11/15/2023]
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy-specific liver disease. It is characterized by pruritus, abnormal liver function and elevated total bile acid (TBA) levels, increasing the risk of maternal and fetal adverse outcomes. Its etiology remains poorly elucidated. Over the years, various omics techniques, including metabolomics, microbiome, genomics, etc., have emerged with the advancement of bioinformatics, providing a new direction for exploring the pathogenesis, diagnosis and treatment of ICP. In this review, we first summarize the role of bile acids and related components in the pathogenesis of ICP and then further illustrate the results of omics studies.
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Affiliation(s)
- Mi Tang
- GCP Institution, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Liling Xiong
- Obstetrics Department, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Jianghui Cai
- Department of Pharmacy, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jinzhu Fu
- Obstetrics Department, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Hong Liu
- Operating Theater, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Ying Ye
- Operating Theater, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Li Yang
- Obstetrics Department, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - ShaSha Xing
- GCP Institution, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, China.
| | - Xiao Yang
- Obstetrics Department, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, China.
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Sanchon-Sanchez P, Herraez E, Macias RIR, Estiu MC, Fortes P, Monte MJ, Marin JJG, Romero MR. Relationship between cholestasis and altered progesterone metabolism in the placenta-maternal liver tandem. Biochim Biophys Acta Mol Basis Dis 2024; 1870:166926. [PMID: 37956602 DOI: 10.1016/j.bbadis.2023.166926] [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: 09/15/2023] [Revised: 10/20/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND In intrahepatic cholestasis of pregnancy (ICP), there are elevated maternal serum levels of total bile acids, progesterone, and some sulfated metabolites, such as allopregnanolone sulfate, which inhibits canalicular function. AIM To investigate the relationship between cholestasis and the expression of crucial enzymes involved in progesterone metabolism in the liver and placenta. METHODS Obstructive cholestasis was induced by bile duct ligation (BDL). RT-qPCR (mRNA) and western blot (protein) were used to determine expression levels. Srd5a1 and Akr1c2 enzymatic activities were assayed by substrate disappearance (progesterone and 5α-dihydroprogesterone, respectively), measured by HPLC-MS/MS. RESULTS BDL induced decreased Srd5a1 and Akr1c2 expression and activity in rat liver, whereas both enzymes were up-regulated in rat placenta. Regarding sulfotransferases, Sult2b1 was also moderately up-regulated in the liver. In placenta from ICP patients, SRD5A1 and AKR1C2 expression was elevated, whereas both genes were down-regulated in liver biopsies collected from patients with several liver diseases accompanied by cholestasis. SRD5A1 and AKR1C2 expression was not affected by incubating human hepatoma HepG2 cells with FXR agonists (chenodeoxycholic acid and GW4064). Knocking-out Fxr in mice did not reduce Srd5a1 and Akr1c14 expression, which was similarly down-regulated by BDL. CONCLUSION SRD5A1 and AKR1C2 expression was markedly altered by cholestasis. This was enhanced in the placenta but decreased in the liver, which is not mediated by FXR. These results suggest that the excess of progesterone metabolites in the serum of ICP patients can involve both enhanced placental production and decreased hepatic clearance. The latter may also occur in other cholestatic conditions.
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Affiliation(s)
- Paula Sanchon-Sanchez
- Experimental Hepatology and Drug Targeting (HEVEPHARM), IBSAL, University of Salamanca, Salamanca, Spain; National Institute for the Study of Liver and Gastrointestinal Diseases (CIBERehd), Madrid, Spain
| | - Elisa Herraez
- Experimental Hepatology and Drug Targeting (HEVEPHARM), IBSAL, University of Salamanca, Salamanca, Spain; National Institute for the Study of Liver and Gastrointestinal Diseases (CIBERehd), Madrid, Spain
| | - Rocio I R Macias
- Experimental Hepatology and Drug Targeting (HEVEPHARM), IBSAL, University of Salamanca, Salamanca, Spain; National Institute for the Study of Liver and Gastrointestinal Diseases (CIBERehd), Madrid, Spain
| | - Maria C Estiu
- Ramon Sarda Mother's and Children's Hospital, Buenos Aires, Argentina
| | - Puri Fortes
- Foundation for Applied Medical Research (FIMA), School of Medicine, University of Navarra, Pamplona, Spain; National Institute for the Study of Liver and Gastrointestinal Diseases (CIBERehd), Madrid, Spain
| | - Maria J Monte
- Experimental Hepatology and Drug Targeting (HEVEPHARM), IBSAL, University of Salamanca, Salamanca, Spain; National Institute for the Study of Liver and Gastrointestinal Diseases (CIBERehd), Madrid, Spain
| | - Jose J G Marin
- Experimental Hepatology and Drug Targeting (HEVEPHARM), IBSAL, University of Salamanca, Salamanca, Spain; National Institute for the Study of Liver and Gastrointestinal Diseases (CIBERehd), Madrid, Spain.
| | - Marta R Romero
- Experimental Hepatology and Drug Targeting (HEVEPHARM), IBSAL, University of Salamanca, Salamanca, Spain; National Institute for the Study of Liver and Gastrointestinal Diseases (CIBERehd), Madrid, Spain
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Dumančić S, Mikuš M, Palčić Z, Habek D, Tešanović M, Mimica MD, Marušić J. Severe Early-Onset Intrahepatic Cholestasis of Pregnancy Following Ovarian Hyperstimulation Syndrome with Pulmonary Presentation after In Vitro Fertilization: Case Report and Systematic Review of Case Reports. Life (Basel) 2024; 14:129. [PMID: 38255744 PMCID: PMC10820620 DOI: 10.3390/life14010129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/03/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy-related liver disease, usually presented in the third trimester with pruritus, elevated transaminase, and serum total bile acids. Evidence shows that it can be developed in the first trimester, more commonly after in vitro fertilization (IVF) procedures, with the presence of ovarian hyperstimulation syndrome (OHSS). METHODS A literature search was conducted in the PubMed/MEDLINE database of case reports/studies reporting early-onset ICP in spontaneous and IVF pregnancies published until July 2023. RESULTS Thirty articles on early-onset ICP were included in the review analysis, with 19 patients who developed ICP in spontaneous pregnancy and 15 patients who developed ICP in IVF pregnancies with or without OHSS. Cases of 1st and 2nd trimester ICP in terms of "early-onset" ICP were pooled to gather additional findings. CONCLUSIONS Proper monitoring should be applied even before expected pregnancy and during IVF procedures in patients with known risk factors for OHSS and ICP development (patient and family history), with proper progesterone supplementation dosage and genetic testing in case of ICP recurrence.
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Affiliation(s)
- Stipe Dumančić
- Department of Obstetrics and Gynecology, Clinical Hospital Center Split, 21 000 Split, Croatia; (S.D.); (M.D.M.)
| | - Mislav Mikuš
- Department of Obstetrics and Gynecology, Clinical Hospital Center Zagreb, 10 000 Zagreb, Croatia
| | - Zdenka Palčić
- Department of Obstetrics and Gynecology, Clinical Hospital Center Split, 21 000 Split, Croatia; (S.D.); (M.D.M.)
| | - Dubravko Habek
- School of Medicine, Catholic University of Croatia, Ilica 242, 10 000 Zagreb, Croatia;
| | - Mara Tešanović
- Department of Obstetrics and Gynecology, General Hospital Dubrovnik, 20 000 Dubrovnik, Croatia;
| | - Marko Dražen Mimica
- Department of Obstetrics and Gynecology, Clinical Hospital Center Split, 21 000 Split, Croatia; (S.D.); (M.D.M.)
| | - Jelena Marušić
- Department of Obstetrics and Gynecology, Clinical Hospital Center Split, 21 000 Split, Croatia; (S.D.); (M.D.M.)
- School of Medicine, University of Split, Soltanska 2, 21 000 Split, Croatia
- University Department of Health Studies, University of Split, R. Boskovica 35, 21 000 Split, Croatia
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Ghanem CI, Manautou JE. Role and Regulation of Hepatobiliary ATP-Binding Cassette Transporters during Chemical-Induced Liver Injury. Drug Metab Dispos 2022; 50:1376-1388. [PMID: 35914951 PMCID: PMC9513844 DOI: 10.1124/dmd.121.000450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/20/2022] [Indexed: 11/22/2022] Open
Abstract
Severity of drug-induced liver injury (DILI) ranges from mild, asymptomatic, and transient elevations in liver function tests to irreversible liver damage, often needing transplantation. Traditionally, DILI is classified mechanistically as high-frequency intrinsic DILI, commonly dose dependent or DILI that rarely occurs and is idiosyncratic in nature. This latter form is not dose dependent and has a pattern of histopathological manifestation that is not always uniform. Currently, a third type of DILI called indirect hepatotoxicity has been described that is associated with the pharmacological action of the drug. Historically, DILI was primarily linked to drug metabolism events; however, the impact of transporter-mediated rates of drug uptake and excretion has gained greater prominence in DILI research. This review provides a comprehensive view of the major findings from studies examining the contribution of hepatic ATP-binding cassette transporters as key contributors to DILI and how changes in their expression and function influence the development, severity, and overall toxicity outcome. SIGNIFICANCE STATEMENT: Drug-induced liver injury (DILI) continues to be a focal point in drug development research. ATP-binding cassette (ABC) transporters have emerged as important determinants of drug detoxification, disposition, and safety. This review article provides a comprehensive analysis of the literature addressing: (a) the role of hepatic ABC transporters in DILI, (b) the influence of genetic mutations in ABC transporters on DILI, and (c) new areas of research emphasis, such as the influence of the gut microbiota and epigenetic regulation, on ABC transporters.
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Affiliation(s)
- Carolina I Ghanem
- Instituto de Investigaciones Farmacológicas (ININFA-UBA-CONICET) (C.I.G.) and Cátedra de Fisiopatología (C.I.G.), Facultad de Farmacia y Bioquímica, Universidad de Buenos Aires, Argentina; and Department of Pharmaceutical Sciences, University of Connecticut, Storrs, Connecticut (J.E.M.)
| | - Jose E Manautou
- Instituto de Investigaciones Farmacológicas (ININFA-UBA-CONICET) (C.I.G.) and Cátedra de Fisiopatología (C.I.G.), Facultad de Farmacia y Bioquímica, Universidad de Buenos Aires, Argentina; and Department of Pharmaceutical Sciences, University of Connecticut, Storrs, Connecticut (J.E.M.)
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Liu W, Wang Q, Chang J, Bhetuwal A, Bhattarai N, Ni X. Circulatory Metabolomics Reveals the Association of the Metabolites With Clinical Features in the Patients With Intrahepatic Cholestasis of Pregnancy. Front Physiol 2022; 13:848508. [PMID: 35899031 PMCID: PMC9309339 DOI: 10.3389/fphys.2022.848508] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: Intrahepatic cholestasis of pregnancy (ICP) is associated with an increased risk of adverse pregnancy to the mother and fetus. As yet, the metabolic profiles and the association of the clinical features remain obscure. Methods: Fifty-seven healthy pregnant women and 52 patients with ICP were recruited in this study. Plasma samples were collected from pregnancies who received prenatal care between 30 and 36 weeks. Untargeted metabolomics to portray the metabolic profiles were performed by LC/MS. Multivariate combined with the univariate analysis was performed to screen out differential metabolites between the ICP and control groups. A de-biased sparse partial correlation (DSPC) network analysis of differential metabolites was conducted to explore the potential mutual regulation among metabolites on the basis of de-sparsified graphical lasso modeling. The pathway analysis was carried out using MetaboAnalyst. Linear regression and Pearson correlation analysis was applied to analyze correlations of bile acid levels, metabolites, newborn weights, and pregnancy outcomes in ICP patients. Results: Conspicuous metabolic changes and choreographed metabolic profiles were disclosed: 125 annotated metabolites and 18 metabolic pathways were disturbed in ICP patients. DSPC networks indicated dense interactions among amino acids and their derivatives, bile acids, carbohydrates, and organic acids. The levels of total bile acid (TBA) were increased in ICP patients with meconium-stained amniotic fluid (MSAF) compared with those without MSAF. An abnormal tryptophan metabolism, elevated long chain saturated fatty acids and estrone sulfate levels, and a low-antioxidant capacity were relevant to increased bile acid levels. Newborn weights were significantly associated with the levels of bile acids and some metabolites of amino acids. Conclusion: Our study revealed the metabolomic profiles in circulation and the correlation of the metabolites with clinical features in ICP patients. Our data suggest that disturbances in metabolic pathways might be associated with adverse pregnancy outcomes.
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Affiliation(s)
- Wenhu Liu
- Department of Gynecology and Obstetrics, International Collaborative Research Center for Medical Metabolomics, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital Central South University, Changsha, China
- School of Pharmacy, School of Basic Medical Sciences and Forensic Medical, North Sichuan Medical College, Nanchong, China
| | - Qiang Wang
- Department of Laboratory Medicine, Translational Medicine Research Center, North Sichuan Medical College, Nanchong, China
- Department of Clinical Laboratory, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Jinxia Chang
- School of Pharmacy, School of Basic Medical Sciences and Forensic Medical, North Sichuan Medical College, Nanchong, China
| | - Anup Bhetuwal
- Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Nisha Bhattarai
- Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xin Ni
- Department of Gynecology and Obstetrics, International Collaborative Research Center for Medical Metabolomics, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital Central South University, Changsha, China
- *Correspondence: Xin Ni,
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6
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Xu L, Yuan Y, Che Z, Tan X, Wu B, Wang C, Xu C, Xiao J. The Hepatoprotective and Hepatotoxic Roles of Sex and Sex-Related Hormones. Front Immunol 2022; 13:939631. [PMID: 35860276 PMCID: PMC9289199 DOI: 10.3389/fimmu.2022.939631] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/13/2022] [Indexed: 12/18/2022] Open
Abstract
Most liver diseases, including acute liver injury, drug-induced liver injury, viral hepatitis, metabolic liver diseases, and end-stage liver diseases, are strongly linked with hormonal influences. Thus, delineating the clinical manifestation and underlying mechanisms of the “sexual dimorphism” is critical for providing hints for the prevention, management, and treatment of those diseases. Whether the sex hormones (androgen, estrogen, and progesterone) and sex-related hormones (gonadotrophin-releasing hormone, luteinizing hormone, follicle-stimulating hormone, and prolactin) play protective or toxic roles in the liver depends on the biological sex, disease stage, precipitating factor, and even the psychiatric status. Lifestyle factors, such as obesity, alcohol drinking, and smoking, also drastically affect the involving mechanisms of those hormones in liver diseases. Hormones deliver their hepatic regulatory signals primarily via classical and non-classical receptors in different liver cell types. Exogenous sex/sex-related hormone therapy may serve as a novel strategy for metabolic liver disease, cirrhosis, and liver cancer. However, the undesired hormone-induced liver injury should be carefully studied in pre-clinical models and monitored in clinical applications. This issue is particularly important for menopause females with hormone replacement therapy (HRT) and transgender populations who want to receive gender-affirming hormone therapy (GAHT). In conclusion, basic and clinical studies are warranted to depict the detailed hepatoprotective and hepatotoxic mechanisms of sex/sex-related hormones in liver disease. Prolactin holds a promising perspective in treating metabolic and advanced liver diseases.
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Affiliation(s)
- Linlin Xu
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuan Yuan
- Clinical Medicine Research Institute, Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhaodi Che
- Clinical Medicine Research Institute, Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xiaozhi Tan
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bin Wu
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Cunchuan Wang
- Clinical Medicine Research Institute, Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Chengfang Xu
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- *Correspondence: Chengfang Xu, ; Jia Xiao,
| | - Jia Xiao
- Clinical Medicine Research Institute, Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
- *Correspondence: Chengfang Xu, ; Jia Xiao,
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Wang P, Yuan P, Lin S, Zhong H, Zhang X, Zhuo Y, Li J, Che L, Feng B, Lin Y, Xu S, Wu D, Burrin DG, Fang Z. Maternal and Fetal Bile Acid Homeostasis Regulated by Sulfated Progesterone Metabolites through FXR Signaling Pathway in a Pregnant Sow Model. Int J Mol Sci 2022; 23:6496. [PMID: 35742938 PMCID: PMC9224516 DOI: 10.3390/ijms23126496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/05/2022] [Accepted: 06/07/2022] [Indexed: 12/24/2022] Open
Abstract
Abnormally elevated circulating bile acids (BA) during pregnancy endanger fetal survival and offspring health; however, the pathology and underlying mechanisms are poorly understood. A total of nineteen pregnant sows were randomly assigned to day 60 of gestation, day 90 of gestation (G60, G90), and the farrowing day (L0), to investigate the intercorrelation of reproductive hormone, including estradiol, progesterone and sulfated progesterone metabolites (PMSs), and BA in the peripheral blood of mother and fetuses during pregnancy. All data were analyzed by Student's t-test or one-way ANOVA of GraphPad Prism and further compared by using the Student-Newman-Keuls test. Correlation analysis was also carried out using the CORR procedure of SAS to study the relationship between PMSs and BA levels in both maternal and fetal serum at G60, G90, and L0. Allopregnanolone sulphate (PM4S) and epiallopregnanolone sulphate (PM5S) were firstly identified in the maternal and fetal peripheral blood of pregnant sows by using newly developed ultraperformance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) methods. Correlation analysis showed that pregnancy-associated maternal BA homeostasis was correlated with maternal serum PM4S levels, whereas fetal BA homeostasis was correlated with fetal serum PM5S levels. The antagonist activity role of PM5S on farnesoid X receptor (FXR)-mediated BA homeostasis and fibroblast growth factor 19 (FGF19) were confirmed in the PM5S and FXR activator co-treated pig primary hepatocytes model, and the antagonist role of PM4S on FXR-mediated BA homeostasis and FGF19 were also identified in the PM4S-treated pig primary hepatocytes model. Together with the high relative expression of FGF19 in pig hepatocytes, the pregnant sow is a promising animal model to investigate the pathogenesis of cholestasis during pregnancy.
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Affiliation(s)
- Peng Wang
- Key Laboratory for Animal Disease Resistance Nutrition of the Ministry of Education, Animal Nutrition Institute, Sichuan Agricultural University, Chengdu 611130, China; (P.W.); (P.Y.); (H.Z.); (X.Z.); (Y.Z.); (J.L.); (L.C.); (B.F.); (Y.L.); (S.X.); (D.W.)
- College of Biology Engineering, Henan University of Technology, Zhengzhou 450000, China
| | - Peiqiang Yuan
- Key Laboratory for Animal Disease Resistance Nutrition of the Ministry of Education, Animal Nutrition Institute, Sichuan Agricultural University, Chengdu 611130, China; (P.W.); (P.Y.); (H.Z.); (X.Z.); (Y.Z.); (J.L.); (L.C.); (B.F.); (Y.L.); (S.X.); (D.W.)
| | - Sen Lin
- Sericultural & Agri-Food Research Institute, Guangdong Academy of Agricultural Sciences, Guangzhou 510000, China;
| | - Heju Zhong
- Key Laboratory for Animal Disease Resistance Nutrition of the Ministry of Education, Animal Nutrition Institute, Sichuan Agricultural University, Chengdu 611130, China; (P.W.); (P.Y.); (H.Z.); (X.Z.); (Y.Z.); (J.L.); (L.C.); (B.F.); (Y.L.); (S.X.); (D.W.)
| | - Xiaoling Zhang
- Key Laboratory for Animal Disease Resistance Nutrition of the Ministry of Education, Animal Nutrition Institute, Sichuan Agricultural University, Chengdu 611130, China; (P.W.); (P.Y.); (H.Z.); (X.Z.); (Y.Z.); (J.L.); (L.C.); (B.F.); (Y.L.); (S.X.); (D.W.)
| | - Yong Zhuo
- Key Laboratory for Animal Disease Resistance Nutrition of the Ministry of Education, Animal Nutrition Institute, Sichuan Agricultural University, Chengdu 611130, China; (P.W.); (P.Y.); (H.Z.); (X.Z.); (Y.Z.); (J.L.); (L.C.); (B.F.); (Y.L.); (S.X.); (D.W.)
| | - Jian Li
- Key Laboratory for Animal Disease Resistance Nutrition of the Ministry of Education, Animal Nutrition Institute, Sichuan Agricultural University, Chengdu 611130, China; (P.W.); (P.Y.); (H.Z.); (X.Z.); (Y.Z.); (J.L.); (L.C.); (B.F.); (Y.L.); (S.X.); (D.W.)
| | - Lianqiang Che
- Key Laboratory for Animal Disease Resistance Nutrition of the Ministry of Education, Animal Nutrition Institute, Sichuan Agricultural University, Chengdu 611130, China; (P.W.); (P.Y.); (H.Z.); (X.Z.); (Y.Z.); (J.L.); (L.C.); (B.F.); (Y.L.); (S.X.); (D.W.)
| | - Bin Feng
- Key Laboratory for Animal Disease Resistance Nutrition of the Ministry of Education, Animal Nutrition Institute, Sichuan Agricultural University, Chengdu 611130, China; (P.W.); (P.Y.); (H.Z.); (X.Z.); (Y.Z.); (J.L.); (L.C.); (B.F.); (Y.L.); (S.X.); (D.W.)
- Key Laboratory for Food Science and Human Health, College of Food Science, Sichuan Agricultural University, Ya’an 625014, China
| | - Yan Lin
- Key Laboratory for Animal Disease Resistance Nutrition of the Ministry of Education, Animal Nutrition Institute, Sichuan Agricultural University, Chengdu 611130, China; (P.W.); (P.Y.); (H.Z.); (X.Z.); (Y.Z.); (J.L.); (L.C.); (B.F.); (Y.L.); (S.X.); (D.W.)
| | - Shengyu Xu
- Key Laboratory for Animal Disease Resistance Nutrition of the Ministry of Education, Animal Nutrition Institute, Sichuan Agricultural University, Chengdu 611130, China; (P.W.); (P.Y.); (H.Z.); (X.Z.); (Y.Z.); (J.L.); (L.C.); (B.F.); (Y.L.); (S.X.); (D.W.)
| | - De Wu
- Key Laboratory for Animal Disease Resistance Nutrition of the Ministry of Education, Animal Nutrition Institute, Sichuan Agricultural University, Chengdu 611130, China; (P.W.); (P.Y.); (H.Z.); (X.Z.); (Y.Z.); (J.L.); (L.C.); (B.F.); (Y.L.); (S.X.); (D.W.)
| | - Douglas G Burrin
- USDA/ARS Children’s Nutrition Research Center, Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Zhengfeng Fang
- Key Laboratory for Animal Disease Resistance Nutrition of the Ministry of Education, Animal Nutrition Institute, Sichuan Agricultural University, Chengdu 611130, China; (P.W.); (P.Y.); (H.Z.); (X.Z.); (Y.Z.); (J.L.); (L.C.); (B.F.); (Y.L.); (S.X.); (D.W.)
- Key Laboratory for Food Science and Human Health, College of Food Science, Sichuan Agricultural University, Ya’an 625014, China
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Krishnan S, Ramsden D, Ferguson D, Stahl SH, Wang J, McGinnity DF, Hariparsad N. Challenges and Opportunities for Improved Drug-Drug Interaction Predictions for Renal OCT2 and MATE1/2-K Transporters. Clin Pharmacol Ther 2022; 112:562-572. [PMID: 35598119 DOI: 10.1002/cpt.2666] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/13/2022] [Indexed: 11/08/2022]
Abstract
Transporters contribute to renal elimination of drugs; therefore drug disposition can be impacted if transporters are inhibited by comedicant drugs. Regulatory agencies have provided guidelines to assess potential drug-drug interaction (DDI) risk for renal organic cation transporter 2 (OCT2) and multidrug and toxin extrusion 1 and 2-K (MATE1/2-K) transporters. Despite this, there are challenges with translating in vitro data using currently available tools to obtain a quantitative assessment of DDI risk in the clinic. Given the high number of drugs and new molecular entities showing in vitro inhibition toward OCT2 and/or MATE1/2-K and the lack of translation to clinically significant effects, it is reasonable to question whether the current in vitro assay design and modeling practice has led to unnecessary clinical evaluation. The aim of this review is to assess and discuss available in vitro and clinical data along with prediction models intended to provide clinical context of risk, including static models proposed by regulatory agencies and physiologically-based pharmacokinetic models, in order to identify best practices and areas of future opportunity. This analysis highlights that different in vitro assay designs, including substrate and cell systems used, strongly influence the derived concentration of drug producing 50% inhibition values and contribute to high variability observed across laboratories. Furthermore, the lack of sensitive index substrates coupled with specific inhibitors for individual transporters necessitates the use of complex models to evaluate clinical DDI risk.
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Affiliation(s)
- Srinivasan Krishnan
- Drug Metabolism and Pharmacokinetics, Oncology Research & Development, AstraZeneca, Boston, Massachusetts, USA
| | - Diane Ramsden
- Drug Metabolism and Pharmacokinetics, Oncology Research & Development, AstraZeneca, Boston, Massachusetts, USA
| | - Douglas Ferguson
- Drug Metabolism and Pharmacokinetics, Oncology Research & Development, AstraZeneca, Boston, Massachusetts, USA
| | - Simone H Stahl
- Cardiovascular, Renal, and Metabolism Safety, Clinical Pharmacology and Safety Sciences, Research & Development, AstraZeneca, Cambridge, UK
| | - Joanne Wang
- Department of Pharmaceutics, University of Washington, Seattle, Washington, USA
| | - Dermot F McGinnity
- Drug Metabolism and Pharmacokinetics, Oncology Research & Development, AstraZeneca, Cambridge, UK
| | - Niresh Hariparsad
- Drug Metabolism and Pharmacokinetics, Oncology Research & Development, AstraZeneca, Boston, Massachusetts, USA
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Waspe J, Beronius A. Development of an Adverse Outcome Pathway for Intrahepatic Cholestasis of Pregnancy. Curr Res Toxicol 2022; 3:100065. [PMID: 35243364 PMCID: PMC8885608 DOI: 10.1016/j.crtox.2022.100065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 12/04/2022] Open
Abstract
Adverse outcome pathways are an established method for knowledge synthesis in toxicology. This method has not yet been applied in the context of clinical research. There are opportunities to apply AOPs to the integration and synthesis of biomedical research. The AOP developed in this paper is an example of how the method could be used to investigate clinical questions.
Adverse Outcome Pathways (AOPs) are a research synthesis tool, used primarily by toxicologists for numerous applications including: hypothesis generation, data integration, biomarker determination, and identification of gaps in current knowledge. The AOP model provides a means for evaluating critical interactions between stressors and biological systems which result in adversity, meaning there is significant potential value in using this model in clinical research. However, AOPs have so far not been applied in this context, which may be attributable to the fact that the method is not yet streamlined with established practices in evidence-based medicine, such as systematic review. Here, we present one approach to developing a clinically focused AOP for intrahepatic cholestasis of pregnancy; aiming to enhance understanding of the mechanistic link between this common, gestational liver disease and its association with preterm birth. Mechanistic aspects of the disease pathogenesis, and use of AOPs to broaden inclusion and improve integration of in vitro and in vivo data in clinical research are discussed. We also demonstrate for the first time how central components of systematic review can be integrated into the development of an AOP.
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10
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Zhang X, Chen Y, Salerno S, Li Y, Zhou L, Zeng X, Li H. Prediction of intrahepatic cholestasis of pregnancy in the first 20 weeks of pregnancy. J Matern Fetal Neonatal Med 2021; 35:6329-6335. [PMID: 34210209 DOI: 10.1080/14767058.2021.1911996] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AIM Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific liver disease associated with a significant risk of fetal complications including pre-term delivery and fetal death. Typically, it was diagnosed in the third trimester of pregnancy. This study utilized characteristics from routine maternal examinations in the first 20 weeks' gestation to predict ICP in pregnant women. METHODS This is a retrospective case-control study. 13,329 medical records were collected on pregnant women presenting to the West China Second University Hospital between December 2017 and December 2018. After screening according to strict criteria, a total of 487 patients, 250 intrahepatic cholestasis of pregnancy cases, and 237 controls were selected for this study. We collected seven maternal characteristics indices for analysis and forty-three routine blood examination indices were obtained from routine hepatic, renal, and coagulation function examinations. The least absolute shrinkage and selection operator regression was applied for variable selection. Classification and regression trees, logistic regression, random forests, and light gradient boosting machines were fit for predictive modeling. We randomly divided 25% of the original data as testing set to conduct internal validation of the performance of the prediction model. The area under the receiver operating characteristic curves (AUC) was used to compare methods. RESULTS Eight variables were selected out as potentially significant predictors that could reliably predict ICP. The sensitivity, specificity, accuracy, and AUC of the final prediction model obtained by light gradient boosting machines were 72.41, 79.69, 76.23, and 79.77%, respectively. Significantly higher platelet large cell ratio, alanine aminotransferase, glutamyl transpeptidase, and fibrinogen levels were found in cases as compared to healthy controls, while activated partial thromboplastin time and mean corpuscular hemoglobin concentration levels were significantly lower (p < .001). CONCLUSIONS The combination of alanine aminotransferase, glutamyl transpeptidase, fibrinogen, platelet large cell ratio, activated partial thromboplastin time, lactate dehydrogenase, creatinine, and mean corpuscular hemoglobin concentration levels can effectively predict ICP in the first 20 weeks of gestation. These could help provide direction for earlier detection and prevention of ICP.
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Affiliation(s)
- Xinyuan Zhang
- Department of Applied Mechanics, College of Architecture and Environment, Sichuan Province Biomechanical Engineering Laboratory, Sichuan University, Chengdu, China
| | - Yu Chen
- Department of Applied Mechanics, College of Architecture and Environment, Sichuan Province Biomechanical Engineering Laboratory, Sichuan University, Chengdu, China.,Medical Big Data Center, Sichuan University, Chengdu, China
| | - Stephen Salerno
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Yi Li
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Libin Zhou
- Department of Computer Science, University of Wisconsin, Wisconsin, WI, USA
| | - Xiaoxi Zeng
- Medical Big Data Center, Sichuan University, Chengdu, China
| | - Huafeng Li
- West China Second University Hospital, Sichuan University, Chengdu, China
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Triggers of benign recurrent intrahepatic cholestasis and its pathophysiology: a review of literature. Acta Gastroenterol Belg 2021; 84:477-486. [PMID: 34599573 DOI: 10.51821/84.3.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Benign recurrent intrahepatic cholestasis (BRIC) is a rare genetic disorder that is characterized by episodes of cholestasis followed by complete resolution. The episodic nature of BRIC raises concerns about its possible trigger factors. Indeed, case reports of this orphan disease have associated BRIC to some triggers. In the absence of any reviews, we reviewed BRIC trigger factors and its pathophysiology. The study consisted of a systematic search for case reports using PubMed. Articles describing a clear case of BRIC associated with a trigger were included resulting in 22 articles that describe 35 patients. Infection was responsible for 54.3% of triggered episodes, followed by hormonal, drugs, and miscellaneous causes reporting as 30%, 10%, and 5.7% respectively. Females predominated with 62.9%. The longest episode ranged between 3 months to 2 years with a mean of 32.37 weeks. The mean age of the first episode was 14.28 ranging between 3 months to 48 years. Winter and autumn were the major seasons during which episodes happened. Hence, BRIC is potentially triggered by infection, which is most commonly a viral infection, hormonal disturbances as seen in oral contraceptive pills and pregnancy state, and less commonly by certain drugs and other causes. The appearance of cholestasis during the first two trimesters of pregnancy compared to intrahepatic cholestasis of pregnancy could help to differentiate between the two conditions. The possible mechanism of BRIC induction implicates a role of BSEP and ATP8B1. While estrogen, drugs, and cytokines are known to affect BSEP, less is known about their action on ATP8B1.
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12
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Langedijk JAGM, Beuers UH, Oude Elferink RPJ. Cholestasis-Associated Pruritus and Its Pruritogens. Front Med (Lausanne) 2021; 8:639674. [PMID: 33791327 PMCID: PMC8006388 DOI: 10.3389/fmed.2021.639674] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/12/2021] [Indexed: 12/17/2022] Open
Abstract
Pruritus is a debilitating symptom of various cholestatic disorders, including primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC) and inherited progressive familial intrahepatic cholestasis (PFIC). The molecular mechanisms leading to cholestasis-associated pruritus are still unresolved and the involved pruritogens are indecisive. As a consequence of pruritus, patients suffer from sleep deprivation, loss of daytime concentration, auto-mutilation and sometimes even suicidal ideations. Current guideline-approved therapy of cholestasis-associated pruritus includes stepwise administration of several medications, which may alleviate complaints in some, but not all affected patients. Therefore, also experimental therapeutic approaches are required to improve patients' quality of life. This article reviews the current state of research on pruritogens and their receptors, and shortly discusses the most recent experimental therapies.
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Affiliation(s)
- Jacqueline A G M Langedijk
- Amsterdam University Medical Centers, Tytgat Institute for Liver and Intestinal Research, Research Institute Amsterdam Gastroenterology, Endocrinology and Metabolism (AGEM), University of Amsterdam, Amsterdam, Netherlands
| | - Ulrich H Beuers
- Amsterdam University Medical Centers, Tytgat Institute for Liver and Intestinal Research, Research Institute Amsterdam Gastroenterology, Endocrinology and Metabolism (AGEM), University of Amsterdam, Amsterdam, Netherlands
| | - Ronald P J Oude Elferink
- Amsterdam University Medical Centers, Tytgat Institute for Liver and Intestinal Research, Research Institute Amsterdam Gastroenterology, Endocrinology and Metabolism (AGEM), University of Amsterdam, Amsterdam, Netherlands
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Lowjaga KAAT, Kirstgen M, Müller SF, Goldmann N, Lehmann F, Glebe D, Geyer J. Long-term trans-inhibition of the hepatitis B and D virus receptor NTCP by taurolithocholic acid. Am J Physiol Gastrointest Liver Physiol 2021; 320:G66-G80. [PMID: 33174454 DOI: 10.1152/ajpgi.00263.2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Human hepatic bile acid transporter Na+/taurocholate cotransporting polypeptide (NTCP) represents the liver-specific entry receptor for the hepatitis B and D viruses (HBV/HDV). Chronic hepatitis B and D affect several million people worldwide, but treatment options are limited. Recently, HBV/HDV entry inhibitors targeting NTCP have emerged as promising novel drug candidates. Nevertheless, the exact molecular mechanism that NTCP uses to mediate virus binding and entry into hepatocytes is still not completely understood. It is already known that human NTCP mRNA expression is downregulated under cholestasis. Furthermore, incubation of rat hepatocytes with the secondary bile acid taurolithocholic acid (TLC) triggers internalization of the rat Ntcp protein from the plasma membrane. In the present study, the long-term inhibitory effect of TLC on transport function, HBV/HDV receptor function, and membrane expression of human NTCP were analyzed in HepG2 and human embryonic kidney (HEK293) cells stably overexpressing NTCP. Even after short-pulse preincubation, TLC had a significant long-lasting inhibitory effect on the transport function of NTCP, but the NTCP protein was still present at the plasma membrane. Furthermore, binding of the HBV/HDV myr-preS1 peptide and susceptibility for in vitro HDV infection were significantly reduced by TLC preincubation. We hypothesize that TLC rapidly accumulates in hepatocytes and mediates long-lasting trans-inhibition of the transport and receptor function of NTCP via a particular TLC-binding site at an intracellularly accessible domain of NTCP. Physiologically, this trans-inhibition might protect hepatocytes from toxic overload of bile acids. Pharmacologically, it provides an interesting novel NTCP target site for potential long-acting HBV/HDV entry inhibitors.NEW & NOTEWORTHY The hepatic bile acid transporter NTCP is a high-affinity receptor for hepatitis B and D viruses. This study shows that TLC rapidly accumulates in NTCP-expressing hepatoma cells and mediates long-lasting trans-inhibition of NTCP's transporter and receptor function via an intracellularly accessible domain, without substantially affecting its membrane expression. This domain is a promising novel NTCP target site for pharmacological long-acting HBV/HDV entry inhibitors.
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Affiliation(s)
- Kira A A T Lowjaga
- Faculty of Veterinary Medicine, Institute of Pharmacology and Toxicology, Justus Liebig University, Giessen, Germany
| | - Michael Kirstgen
- Faculty of Veterinary Medicine, Institute of Pharmacology and Toxicology, Justus Liebig University, Giessen, Germany
| | - Simon F Müller
- Faculty of Veterinary Medicine, Institute of Pharmacology and Toxicology, Justus Liebig University, Giessen, Germany
| | - Nora Goldmann
- Institute of Medical Virology, National Reference Center for Hepatitis B Viruses and Hepatitis D Viruses, Justus Liebig University, Giessen, Germany
| | - Felix Lehmann
- Institute of Medical Virology, National Reference Center for Hepatitis B Viruses and Hepatitis D Viruses, Justus Liebig University, Giessen, Germany
| | - Dieter Glebe
- Institute of Medical Virology, National Reference Center for Hepatitis B Viruses and Hepatitis D Viruses, Justus Liebig University, Giessen, Germany
| | - Joachim Geyer
- Faculty of Veterinary Medicine, Institute of Pharmacology and Toxicology, Justus Liebig University, Giessen, Germany
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Ozawa S, Miura T, Terashima J, Habano W, Ishida S. Recent Progress in Prediction Systems for Drug-induced Liver Injury Using in vitro Cell Culture. Drug Metab Lett 2020; 14:25-40. [PMID: 33267768 DOI: 10.2174/1872312814666201202112610] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/26/2020] [Accepted: 11/03/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND In order to avoid drug-induced liver injury (DILI), in vitro assays, which enable the assessment of both metabolic activation and immune reaction processes that ultimately result in DILI, are needed. OBJECTIVE In this study, the recent progress in the application of in vitro assays using cell culture systems is reviewed for potential DILI-causing drugs/xenobiotics and a mechanistic study on DILI, as well as for the limitations of in vitro cell culture systems for DILI research. METHODS Information related to DILI was collected through a literature search of the PubMed database. RESULTS The initial biological event for the onset of DILI is the formation of cellular protein adducts after drugs have been metabolically activated by drug metabolizing enzymes. The damaged peptides derived from protein adducts lead to the activation of CD4+ helper T lymphocytes and recognition by CD8+ cytotoxic T lymphocytes, which destroy hepatocytes through immunological reactions. Because DILI is a major cause of drug attrition and drug withdrawal, numerous in vitro systems consisting of hepatocytes and immune/inflammatory cells, or spheroids of human primary hepatocytes containing non-parenchymal cells have been developed. These cellular-based systems have identified DILIinducing drugs with approximately 50% sensitivity and 90% specificity. CONCLUSION Different co-culture systems consisting of human hepatocyte-derived cells and other immune/inflammatory cells have enabled the identification of DILI-causing drugs and of the actual mechanisms of action.
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Affiliation(s)
- Shogo Ozawa
- Department of Clinical Pharmaceutical Sciences, Division of Pharmacodynamics and Molecular Genetics, School of Pharmacy, Iwate Medical University, Yahaba. Japan
| | - Toshitaka Miura
- Department of Clinical Pharmaceutical Sciences, Division of Pharmacodynamics and Molecular Genetics, School of Pharmacy, Iwate Medical University, Yahaba. Japan
| | - Jun Terashima
- Department of Clinical Pharmaceutical Sciences, Division of Pharmacodynamics and Molecular Genetics, School of Pharmacy, Iwate Medical University, Yahaba. Japan
| | - Wataru Habano
- Department of Clinical Pharmaceutical Sciences, Division of Pharmacodynamics and Molecular Genetics, School of Pharmacy, Iwate Medical University, Yahaba. Japan
| | - Seiichi Ishida
- Department of Pharmacology, National Institute of Health Sciences, Kawasaki. Japan
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Zipori Y, Bachar G, Farago N, Lauterbach R, Weissman A, Beloosesky R, Weiner Z. Vaginal progesterone treatment for the prevention of preterm birth and intrahepatic cholestasis of pregnancy: A case-control study. Eur J Obstet Gynecol Reprod Biol 2020; 253:117-120. [PMID: 32866855 DOI: 10.1016/j.ejogrb.2020.08.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 08/14/2020] [Accepted: 08/21/2020] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Intrahepatic cholestasis of pregnancy (ICP) is associated with a distinctive maternal pruritus, abnormal liver function tests, raised serum total bile acids, and increased rates of adverse fetal outcomes, including intrauterine fetal death. Progesterone has been implicated in the pathogenesis of ICP. We aimed to evaluate whether the incidence of ICP is altered in women receiving long-term daily vaginal progesterone, indicated for a short cervical length. STUDY DESIGN A matched 1:3 case-control study of pregnant women between January 2014 and January 2019. Study cases included pregnant women with the diagnosis of ICP. Control cases were women without ICP. The primary outcome was the rate of vaginal progesterone treatment among the groups. RESULTS The use of vaginal progesterone throughout pregnancy was higher in the ICP group compared with the control group (8/174 [4.6 %] versus 6/522 [1.1 %], respectively, P = 0.03, odds ratio 4 [95 % confidence interval 1.4-11.7]). CONCLUSIONS Pregnant women treated with long-term vaginal progesterone preparations for the prevention of preterm birth are at increased risk of developing ICP. In the presence of pruritus during pregnancy, we recommend an early consultation and diagnostic test to confirm or rule-out ICP.
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Affiliation(s)
- Yaniv Zipori
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.
| | - Gal Bachar
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Naama Farago
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Roy Lauterbach
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Amir Weissman
- High-Risk Pregnancy Unit, Lin Medical Center, Clalit Health Services, Haifa, Israel
| | - Ron Beloosesky
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Zeev Weiner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel; Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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16
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Walker KF, Chappell LC, Hague WM, Middleton P, Thornton JG. Pharmacological interventions for treating intrahepatic cholestasis of pregnancy. Cochrane Database Syst Rev 2020; 7:CD000493. [PMID: 32716060 PMCID: PMC7389072 DOI: 10.1002/14651858.cd000493.pub3] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder that can develop in pregnancy. It occurs when there is a build-up of bile acids in the maternal blood. It has been linked to adverse maternal and fetal/neonatal outcomes. As the pathophysiology is poorly understood, therapies have been largely empiric. As ICP is an uncommon condition (incidence less than 2% a year), many trials have been small. Synthesis, including recent larger trials, will provide more evidence to guide clinical practice. This review is an update of a review first published in 2001 and last updated in 2013. OBJECTIVES To assess the effects of pharmacological interventions to treat women with intrahepatic cholestasis of pregnancy, on maternal, fetal and neonatal outcomes. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (13 December 2019), and reference lists of retrieved studies. SELECTION CRITERIA Randomised or quasi-randomised controlled trials, including cluster-randomised trials and trials published in abstract form only, that compared any drug with placebo or no treatment, or two drug intervention strategies, for women with a clinical diagnosis of intrahepatic cholestasis of pregnancy. DATA COLLECTION AND ANALYSIS The review authors independently assessed trials for eligibility and risks of bias. We independently extracted data and checked these for accuracy. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 26 trials involving 2007 women. They were mostly at unclear to high risk of bias. They assessed nine different pharmacological interventions, resulting in 14 different comparisons. We judged two placebo-controlled trials of ursodeoxycholic acid (UDCA) in 715 women to be at low risk of bias. The ten different pharmacological interventions were: agents believed to detoxify bile acids (UCDA) and S-adenosylmethionine (SAMe); agents used to bind bile acids in the intestine (activated charcoal, guar gum, cholestyramine); Chinese herbal medicines (yinchenghao decoction (YCHD), salvia, Yiganling and Danxioling pill (DXLP)), and agents aimed to reduce bile acid production (dexamethasone) Compared with placebo, UDCA probably results in a small improvement in pruritus score measured on a 100 mm visual analogue scale (VAS) (mean difference (MD) -7.64 points, 95% confidence interval (CI) -9.69 to -5.60 points; 2 trials, 715 women; GRADE moderate certainty), where a score of zero indicates no itch and a score of 100 indicates severe itching. The evidence for fetal distress and stillbirth were uncertain, due to serious limitations in study design and imprecision (risk ratio (RR) 0.70, 95% CI 0.35 to 1.40; 6 trials, 944 women; RR 0.33, 95% CI 0.08 to 1.37; 6 trials, 955 women; GRADE very low certainty). We found very few differences for the other comparisons included in this review. There is insufficient evidence to indicate if SAMe, guar gum, activated charcoal, dexamethasone, cholestyramine, Salvia, Yinchenghao decoction, Danxioling and Yiganling, or Yiganling alone or in combination are effective in treating women with intrahepatic cholestasis of pregnancy. AUTHORS' CONCLUSIONS When compared with placebo, UDCA administered to women with ICP probably shows a reduction in pruritus. However the size of the effect is small and for most pregnant women and clinicians, the reduction may fall below the minimum clinically worthwhile effect. The evidence was unclear for other adverse fetal outcomes, due to very low-certainty evidence. There is insufficient evidence to indicate that SAMe, guar gum, activated charcoal, dexamethasone, cholestyramine, YCHD, DXLP, Salvia, Yiganling alone or in combination are effective in treating women with cholestasis of pregnancy. There are no trials of the efficacy of topical emollients. Further high-quality trials of other interventions are needed in order to identify effective treatments for maternal itching and preventing adverse perinatal outcomes. It would also be helpful to identify those women who are mostly likely to respond to UDCA (for example, whether bile acid concentrations affect how women with ICP respond to treatment with UDCA).
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Affiliation(s)
- Kate F Walker
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London, London, UK
| | - William M Hague
- Women's and Children's Hospital, North Adelaide, Australia
- Robinson Research Institute, The University of Adelaide, North Adelaide, Australia
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
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Ito K, Sjöstedt N, Brouwer KLR. Mechanistic Modeling of the Hepatic Disposition of Estradiol-17 β-Glucuronide in Sandwich-Cultured Human Hepatocytes. Drug Metab Dispos 2019; 48:116-122. [PMID: 31744810 DOI: 10.1124/dmd.119.088898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/12/2019] [Indexed: 11/22/2022] Open
Abstract
Estradiol-17β-glucuronide (E217G) is an estrogen metabolite that has cholestatic properties. In humans, circulating E217G is transported into hepatocytes by organic anion transporting polypeptides (OATPs) and is excreted into bile by multidrug-resistance associated protein 2 (MRP2). E217G is also a substrate of the basolateral efflux transporters MRP3 and MRP4, which translocate E217G from hepatocytes to blood. However, the contribution of basolateral efflux to hepatocyte disposition of E217G has not been evaluated previously. To address this question, E217G disposition was studied in sandwich-cultured human hepatocytes and mechanistic modeling was applied to calculate clearance values (mean ± S.D.) for uptake, intrinsic biliary excretion (CLint,bile) and intrinsic basolateral efflux (CLint,BL). The biliary excretion index of E217G was 45% ± 6%. The CLint,BL of E217G [0.18 ± 0.03 (ml/min)/g liver) was 1.6-fold higher than CLint,bile [0.11 ± 0.06 (ml/min)/g liver]. Simulations were performed to study the effects of increased CLint,BL and a concomitant decrease in CLint,bile on hepatic E217G exposure. Results demonstrated that increased CLint,BL can effectively reduce hepatocellular and biliary exposure to this potent cholestatic agent. Simulations also revealed that basolateral efflux can compensate for impaired biliary excretion and, vice versa, to avoid accumulation of E217G in hepatocytes. However, when both clearance processes are impaired by 90%, hepatocyte E217G exposure increases up to 10-fold. These data highlight the contribution of basolateral efflux transport, in addition to MRP2-mediated biliary excretion, to E217G disposition in human hepatocytes. This elimination route could be important, especially in cases where basolateral efflux is induced, such as cholestasis. SIGNIFICANCE STATEMENT: The disposition of the cholestatic estrogen metabolite estradiol-17β-glucuronide (E217G) was characterized in sandwich-cultured human hepatocytes. The intrinsic basolateral efflux clearance was estimated to be 1.6-fold higher than the intrinsic biliary excretion clearance, emphasizing the contribution of basolateral elimination in addition to biliary excretion. Simulations highlight how hepatocytes can effectively cope with increased E217G through the regulation of both basolateral and biliary transporters.
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Affiliation(s)
- Katsuaki Ito
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.I., N.S., K.L.R.B.); and DMPK Research Department, Teijin Pharma Limited, Hino, Tokyo, Japan (K.I.)
| | - Noora Sjöstedt
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.I., N.S., K.L.R.B.); and DMPK Research Department, Teijin Pharma Limited, Hino, Tokyo, Japan (K.I.)
| | - Kim L R Brouwer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.I., N.S., K.L.R.B.); and DMPK Research Department, Teijin Pharma Limited, Hino, Tokyo, Japan (K.I.)
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18
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Beneficial and Deleterious Effects of Female Sex Hormones, Oral Contraceptives, and Phytoestrogens by Immunomodulation on the Liver. Int J Mol Sci 2019; 20:ijms20194694. [PMID: 31546715 PMCID: PMC6801544 DOI: 10.3390/ijms20194694] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/13/2019] [Accepted: 09/20/2019] [Indexed: 12/11/2022] Open
Abstract
The liver is considered the laboratory of the human body because of its many metabolic processes. It accomplishes diverse activities as a mixed gland and is in continuous cross-talk with the endocrine system. Not only do hormones from the gastrointestinal tract that participate in digestion regulate the liver functions, but the sex hormones also exert a strong influence on this sexually dimorphic organ, via their receptors expressed in liver, in both health and disease. Besides, the liver modifies the actions of sex hormones through their metabolism and transport proteins. Given the anatomical position and physiological importance of liver, this organ is evidenced as an immune vigilante that mediates the systemic immune response, and, in turn, the immune system regulates the hepatic functions. Such feedback is performed by cytokines. Pro-inflammatory and anti-inflammatory cytokines are strongly involved in hepatic homeostasis and in pathological states; indeed, female sex hormones, oral contraceptives, and phytoestrogens have immunomodulatory effects in the liver and the whole organism. To analyze the complex and interesting beneficial or deleterious effects of these drugs by their immunomodulatory actions in the liver can provide the basis for either their pharmacological use in therapeutic treatments or to avoid their intake in some diseases.
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19
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Familial intrahepatic cholestasis: New and wide perspectives. Dig Liver Dis 2019; 51:922-933. [PMID: 31105019 DOI: 10.1016/j.dld.2019.04.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 04/01/2019] [Accepted: 04/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Progressive familial intrahepatic cholestasis (PFIC) includes autosomal recessive cholestatic rare diseases of childhood. AIMS To update the panel of single genes mutations involved in familial cholestasis. METHODS PubMed search for "familial intrahepatic cholestasis" alone as well as in combination with other key words was performed considering primarily original studies and meta-analyses. RESULTS PFIC1 involves ATP8B1 gene encoding for aminophospholipid flippase FIC1. PFIC2 includes ABCB11 gene, encoding for protein functioning as bile salt export pump. PFIC3 is due to mutations of ABCB4 gene responsible for the synthesis of class III multidrug resistance P-glycoprotein flippase. PFIC4 and PFIC5 involve tight junction protein-2 gene and NR1H4 gene encoding for farnesoid X receptor. Benign Intrahepatic Cholestasis, Intrahepatic Cholestasis of Pregnancy and Low-phospholipid-associated cholelithiasis involve the same genes and are characterized by intermittent attacks of cholestasis, no progression to cirrhosis, reversible pregnancy-specific cholestasis and cholelithiasis in young people. Blood and liver tissue levels of bile-excreted drugs can be influenced by the presence of mutations in PFIC genes, causing drug-induced cholestasis. Mutations in PFIC genes might increase the risk of liver cancer. CONCLUSION There is a high proportion of unexplained cholestasis potentially caused by specific genetic pathophysiologic pathways. The use of next generation sequencing and whole-exome sequencing could improve the diagnostic process in this setting.
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Li H, Liu B, Gu C, Zeng X, Liu Y, Zhang S, Gong H, Shao Y, Yao Z, An R. Relations of neuropeptide Y and heme oxygenase-1 expressions with fetal brain injury in rats with intrahepatic cholestasis of pregnancy. Acta Cir Bras 2019; 34:e201900401. [PMID: 31066785 PMCID: PMC6583935 DOI: 10.1590/s0102-865020190040000001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 03/03/2019] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To investigate the relations of neuropeptide Y (NPY) and heme oxygenase-1 (HO-1) expressions with fetal brain injury in rats with intrahepatic cholestasis of pregnancy (ICP). METHODS Sixty rats pregnant for 15 days were randomly divided into experimental and control groups. The ICP model was established in experimental group. On the 21st day, the blood biochemical test, histopathological examination of pregnant rat liver and fetal brain tissues and immunohistochemical analysis of fetal rat brain tissues were performed. RESULTS On the 21st day, the alanineaminotransferase, aspartate aminotransferase and total bile acid levels in experimental group were significantly higher than control group (P<0.01). Compared with control group, there was obvious vacuolar degeneration in pregnant rat liver tissue and fetal brain tissue in experimental group. NPY expression in fetal brain tissue was negative in control group and positive in experimental group. HO-1 expression in fetal brain tissue was strongly positive in control group and positive in experimental group. There was significant difference of immunohistochemical staining optical density between two groups (P<0.01). CONCLUSION In fetal brain of ICP rats, the NPY expression is increased, and the HO-1 expression is decreased, which may be related to the fetal brain injury.
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Affiliation(s)
- Hongxia Li
- Doctor, Department of Obstetrics and Gynecology, The First Affiliated Hospital, Xi'an Jiao Tong University; and Department of Gynecology, Affiliated Hospital of Yan'an University, China. Design of the study, acquisition of data, technical procedures, final approval
| | - Bofeng Liu
- Master, Department of Anatomy, Yan'an University Medical College, China. Acquisition of data, technical procedures, manuscript preparation, final approval
| | - Chunyan Gu
- Bachelor, Department of Gynecology, Affiliated Hospital of Yan'an University, China. Acquisition of data, technical procedures, final approval
| | - Xiao Zeng
- Master, Affiliated Hospital of Yan'an University, China. Acquisition of data, technical procedures, final approval
| | - Yali Liu
- Master, Affiliated Hospital of Yan'an University, China. Acquisition of data, technical procedures, final approval
| | - Susu Zhang
- Master, Affiliated Hospital of Yan'an University, China. Acquisition of data, technical procedures, final approval
| | - Haiye Gong
- Master, Affiliated Hospital of Yan'an University, China. Acquisition of data, technical procedures, final approval
| | - Yong Shao
- Master, Department of Obstetrics and Gynecology, The First Affiliated Hospital, Chongqing Medical University, China. Statistical analysis, manuscript preparation, final approval
| | - Zhenwei Yao
- Master, Department of Obstetrics and Gynecology, The First Affiliated Hospital, Chongqing Medical University, China. Statistical analysis, manuscript preparation, final approval
| | - Ruifang An
- Doctor, Department of Obstetrics and Gynecology, The First Affiliated Hospital, Xi'an Jiao Tong University, China. Design of the study, manuscript preparation, final approval
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Disrupted compensatory response mediated by Wolfram syndrome 1 protein and corticotrophin-releasing hormone family peptides in early-onset intrahepatic cholestasis pregnancy. Placenta 2019; 83:63-71. [PMID: 31477210 DOI: 10.1016/j.placenta.2019.06.378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 03/20/2019] [Accepted: 06/21/2019] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The most adverse perinatal outcome of intrahepatic cholestasis of pregnancy (ICP) is sudden fetal death related to acute fetoplacental hypoxia. Corticotrophin-releasing hormone (CRH), urocortin (UCN), and Wolfram syndrome 1 (WFS1) proteins may have a compensatory response to hypoxic stress. METHODS A total of 108 singleton pregnant women were divided into three groups: control, late-onset ICP, and early-onset ICP. Enzyme-linked immunosorbent assays were used to detected maternal serum CRH, UCN, and WFS1 levels. Western blotting and real-time polymerase chain reaction were conducted to quantify placental protein and mRNA levels of CRH, UCN, and WFS1. Pearson correlation scatterplots and Pearson correlation matrix were employed to testify the correlation. RESULTS Placental WFS1 had a positive relation with placental UCN (r = 0.69, P < 0.05) and serum UCN (r = 0.36, P < 0.05). Placental CRH was positively correlated with maternal serum CRH (r = 0.53, P < 0.05). Maternal serum and placental levels of CRH, UCN, and WFS1 significantly increased in the early-onset ICP group compared with the control group (P < 0.05). Placental levels of UCN and WFS1 in the early-onset ICP group were significantly elevated and higher in comparison with the late-onset ICP group (P < 0.05). However, the transcriptional levels of CRH, UCN, and WFS1 were impaired in the early-onset ICP group. DISCUSSION Our study revealed that transcription and translation of WFS1, CRH, and UCN were altered during pregnancies complicated by early-onset ICP. This disrupted compensatory response mediated by WFS1 and CRH family peptides in early-onset ICP may play a significant role in the pathogenesis of sudden fetal death in acute fetal hypoxia.
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22
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Zhu B, Yin P, Ma Z, Ma Y, Zhang H, Kong H, Zhu Y. Characteristics of bile acids metabolism profile in the second and third trimesters of normal pregnancy. Metabolism 2019; 95:77-83. [PMID: 30959040 DOI: 10.1016/j.metabol.2019.04.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/19/2019] [Accepted: 04/03/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE Bile acids are a group of cholesterol metabolites functioning as key regulators of glucose, lipid, and energy metabolism. Their homeostatic control is essential to the physiology of the normal pregnancy. Abnormalities of bile acids regulation in pregnancy lead to intrahepatic cholestasis of pregnancy, a serious condition associated with a number of fetal and maternal morbidities. Dysregulation of glucose and lipids is also tied to perturbations in bile acid concentrations. Changes in bile acid metabolic profiles in the second and third trimesters of pregnancy have been incompletely explored. We seek to establish pregnancy-specific normative ranges for a number of bile acids in women in the second and third trimesters and explore changes in their concentrations in the period from 12 to 40 weeks gestation. PROCEDURE In this cross-sectional study, a total of 782 normal pregnant women were enrolled including n = 290 in the second trimester (12-28 weeks) and n = 492 in the third trimester (29-40 weeks). The concentrations of 14 bile acids were measured by liquid chromatography and mass spectrometry (LC-MS) and compared at various time points. Reference intervals of these bile acids were calculated using standard statistical techniques. RESULTS A reference interval profile of 14 bile acids from a cohort of 782 normal pregnant women was developed. Significant differences in concentration were found between the second trimester and the third trimester. Unconjugated bile acids dominate the bile acid profile in the second trimester, while conjugated bile acids, especially (taurine-conjugated) dominate in the third trimester. 28-31 weeks gestation was the notable change period of bile acid metabolism. CONCLUSION This study establishes pregnancy-specific reference intervals for bile acids in the second and third trimesters. As bile acid composition changes with gestational age, this study establishes a foundation for trimester-specific clinical interpretation of bile acid metabolic profiles in pregnant women.
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Affiliation(s)
- Bo Zhu
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Clinical Prenatal Diagnosis Center, Women's Hospital, School of Medicine, Zhejiang University, China
| | - Peiyuan Yin
- Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, China; The First affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhixin Ma
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Clinical Prenatal Diagnosis Center, Women's Hospital, School of Medicine, Zhejiang University, China
| | - Yu Ma
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Clinical Prenatal Diagnosis Center, Women's Hospital, School of Medicine, Zhejiang University, China
| | - Hong Zhang
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Clinical Prenatal Diagnosis Center, Women's Hospital, School of Medicine, Zhejiang University, China
| | - Hongwei Kong
- Key Laboratory of Separation Science for Analytical Chemistry, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, China
| | - Yuning Zhu
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Clinical Prenatal Diagnosis Center, Women's Hospital, School of Medicine, Zhejiang University, China.
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Šimják P, Hill M, Pařízek A, Vítek L, Velíková M, Dušková M, Kancheva R, Bulant J, Koucký M, Kokrdová Z, Adamcová K, Černý A, Hájek Z, Stárka L. May circulating steroids reveal a predisposition to intrahepatic cholestasis of pregnancy in non-pregnant women? Physiol Res 2018; 67:S499-S510. [PMID: 30484676 DOI: 10.33549/physiolres.934028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a frequent liver disorder, mostly occurring in the third trimester. ICP is not harmful to the mothers but threatens the fetus. The authors evaluated steroid alterations in maternal and mixed umbilical blood to elucidate their role in the ICP development. Ten women with ICP were included in the study. Steroids in the maternal blood were measured by Gas Chromatography-Mass Spectrometry (GC-MS) (n=58) and RIA (n=5) at the diagnosis of ICP, labor, day 5 postpartum, week 3 postpartum and week 6 postpartum. The results were evaluated by ANOVA consisting of the subject factor, between subject factors ICP, gestational age at the diagnosis of ICP and gestational age at labor, within-subject factor Stage and ICP × Stage interaction. The 17 controls were firstly examined in the week 36 of gestation. ICP patients showed reduced CYP17A1 activity in the C17,20 lyase step thus shifting the balance between the toxic conjugated pregnanediols and harmless sulfated 5alpha/beta-reduced-17-oxo C19 steroids. Hence, more toxic metabolites originating in maternal liver from the placental pregnanes may penetrate backward to the fetal circulation. As these alterations persist in puerperium, the circulating steroids could be potentially used for predicting the predisposition to ICP even before next pregnancy.
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Affiliation(s)
- P Šimják
- Department of Gynecology and Obstetrics, General University Hospital and First Faculty of Medicine, Charles University in Prague, Czech Republic, Department of Steroids and Proteohormones, Institute of Endocrinology, Prague, Czech Republic.
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Ovadia C, Lövgren-Sandblom A, Edwards LA, Langedijk J, Geenes V, Chambers J, Cheng F, Clarke L, Begum S, Noori M, Pusey C, Padmagirison R, Agarwal S, Peerless J, Cheesman K, Heneghan M, Oude Elferink R, Patel VC, Marschall HU, Williamson C. Therapeutic plasma exchange as a novel treatment for severe intrahepatic cholestasis of pregnancy: Case series and mechanism of action. J Clin Apher 2018; 33:638-644. [PMID: 30321466 DOI: 10.1002/jca.21654] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/19/2018] [Accepted: 07/30/2018] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Intrahepatic cholestasis of pregnancy is characterised by pruritus and elevated serum bile acids. The pruritus can be severe, and pharmacological options achieve inconsistent symptomatic improvement. Raised bile acids are linearly associated with adverse fetal outcomes, with existing management of limited benefit. We hypothesised that therapeutic plasma exchange removes pruritogens and lowers total bile acid concentrations, and improves symptoms and biochemical abnormalities in severe cases that have not responded to other treatments. METHODS Four women with severe pruritus and hypercholanemia were managed with therapeutic plasma exchange. Serial blood biochemistry and visual analogue scores of itch severity were obtained. Blood and waste plasma samples were collected before and after exchange; individual bile acids and sulfated progesterone metabolites were measured with HPLC-MS, autotaxin activity and cytokine profiles with enzymatic methods. Results were analysed using segmental linear regression to describe longitudinal trends, and ratio t tests. RESULTS Total bile acids and visual analogue itch scores demonstrated trends to transiently improve following plasma exchange, with temporary symptomatic benefit reported. Individual bile acids (excluding the drug ursodeoxycholic acid), and the sulfated metabolites of progesterone reduced following exchange (P = .03 and P = .04, respectively), whilst analysis of waste plasma demonstrated removal of autotaxin and cytokines. CONCLUSIONS Therapeutic plasma exchange can lower potentially harmful bile acids and improve itch, likely secondary to the demonstrated removal of pruritogens. However, the limited current experience and potential complications, along with minimal sustained symptomatic benefit, restrict its current use to women with the most severe disease for whom other treatment options have been exhausted.
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Affiliation(s)
- Caroline Ovadia
- Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Anita Lövgren-Sandblom
- Department of Clinical Chemistry, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Lindsey A Edwards
- Division of Transplantation, Immunology and Mucosal Biology, King's College London, London, United Kingdom
| | - Jacqueline Langedijk
- Academic Medical Center, Tytgat Institute for Liver and Intestinal Research, Amsterdam, The Netherlands
| | - Victoria Geenes
- Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Jenny Chambers
- Department of Women and Children's Health, King's College London, London, United Kingdom.,Women's Health Research Centre, Imperial College London, London, United Kingdom
| | - Floria Cheng
- Women's Health Research Centre, Imperial College London, London, United Kingdom
| | - Louise Clarke
- Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Shahina Begum
- Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Muna Noori
- Department of Obstetrics and Gynaecology, Imperial College Hospitals, London, United Kingdom
| | - Charles Pusey
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Radhika Padmagirison
- Department of Obstetrics and Gynaecology, Lister Hospital, Stevenage, Hertfordshire, United Kingdom
| | - Sangita Agarwal
- Department of Rheumatology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - James Peerless
- Department of Anaesthetics, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Kate Cheesman
- Department of Anaesthetics, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Michael Heneghan
- Division of Transplantation, Immunology and Mucosal Biology, King's College London, London, United Kingdom
| | - Ronald Oude Elferink
- Academic Medical Center, Tytgat Institute for Liver and Intestinal Research, Amsterdam, The Netherlands
| | - Vishal C Patel
- Division of Transplantation, Immunology and Mucosal Biology, King's College London, London, United Kingdom
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Catherine Williamson
- Department of Women and Children's Health, King's College London, London, United Kingdom
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Tayyar AT, Tayyar A, Atakul T, Yayla CA, Kilicci C, Eser A, Karakus R, Herkiloglu D, Cundubey CR, Tayyar M. Could first- and second-trimester biochemical markers for Down syndrome have a role in predicting intrahepatic cholestasis of pregnancy? Arch Med Sci 2018; 14:846-850. [PMID: 30002703 PMCID: PMC6040116 DOI: 10.5114/aoms.2017.69865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 08/24/2017] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The aim of this study is to compare first- and second-trimester Down syndrome biochemical screening markers in intrahepatic cholestasis of pregnancy (ICP) and normal pregnancies. MATERIAL AND METHODS This observational case-control study was conducted at Health Sciences University Zeynep Kamil Maternity and Children's Health Training and Research Hospital and the Department of Obstetrics and Gynecology at Erciyes University Medical Faculty during 2016-2017. The study included 165 patients, and consisted of 62 women who had been diagnosed with ICP (the ICP-diagnosed group) and 103 healthy pregnant women (the control group). First-trimester free β-human chorionic gonadotropin (β-hCG), pregnancy-associated plasma protein-A (PAPP-A) and second-trimester total β-hCG, estriol (E3), α-fetoprotein (AFP), and inhibin A levels were compared between the two groups. RESULTS The mean patient age was 28.67 ±5.96 years, with no significant difference between the groups (p > 0.05). Average PAPP-A levels were significantly lower in the ICP-diagnosed group (p < 0.001). When the cut-off value for PAPP-A was taken as ≤ 0.93 multiple of median (MoM), the sensitivity and specificity values for ICP were 73.8% and 56.3%, respectively (95% CI, AUC ± SE: 0.663 ±0.042). CONCLUSIONS The decrease in PAPP-A MoM value indicates an increase in the risk of developing ICP, while changes in other markers were not sufficient to predict ICP.
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Affiliation(s)
- Ahter Tanay Tayyar
- Department of Obstetrics and Gynecology, Health Sciences University, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Tayyar
- Department of Obstetrics and Gynecology, Health Sciences University, Kanuni Sultan Süleyman Education and Research Hospital, Istanbul, Turkey
| | - Tolga Atakul
- Department of Obstetrics and Gynecology, Faculty of Medicine, Adnan Menderes University, Aydın, Turkey
| | - Cigdem Abide Yayla
- Department of Obstetrics and Gynecology, Health Sciences University, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul, Turkey
| | - Cetin Kilicci
- Department of Obstetrics and Gynecology, Health Sciences University, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Eser
- Department of Obstetrics and Gynecology, Health Sciences University, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul, Turkey
| | - Resul Karakus
- Department of Obstetrics and Gynecology, Health Sciences University, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul, Turkey
| | - Dilsat Herkiloglu
- Department of Obstetrics and Gynecology, Health Sciences University, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul, Turkey
| | - Cevat Rifat Cundubey
- Department of Obstetrics and Gynecology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Mehmet Tayyar
- Department of Obstetrics and Gynecology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
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Pataia V, Dixon PH, Williamson C. Pregnancy and bile acid disorders. Am J Physiol Gastrointest Liver Physiol 2017; 313:G1-G6. [PMID: 28450276 DOI: 10.1152/ajpgi.00028.2017] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/20/2017] [Accepted: 04/20/2017] [Indexed: 01/31/2023]
Abstract
During pregnancy, extensive adaptations in maternal metabolic and immunological physiology occur. Consequently, preexisting disease may be exacerbated or attenuated, and new disease susceptibility may be unmasked. Cholestatic diseases, characterized by a supraphysiological raise in bile acid levels, require careful monitoring during pregnancy. This review describes the latest advances in the knowledge of intrahepatic cholestasis of pregnancy (ICP), the most common bile acid disorder specific to pregnancy, with a focus on the disease etiology and potential mechanisms of ICP-associated adverse pregnancy outcomes, including fetal demise. The course of preexisting cholestatic conditions in pregnancy is considered, including primary sclerosing cholangitis, primary biliary cholangitis, biliary atresia, and Alagille syndrome. The currently accepted treatments for cholestasis in pregnancy and promising new therapeutics for the condition are described.
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Affiliation(s)
- Vanessa Pataia
- Division of Women's Health, King's College London, London, United Kingdom
| | - Peter H Dixon
- Division of Women's Health, King's College London, London, United Kingdom
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McIlvride S, Dixon PH, Williamson C. Bile acids and gestation. Mol Aspects Med 2017; 56:90-100. [PMID: 28506676 DOI: 10.1016/j.mam.2017.05.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/27/2017] [Accepted: 05/08/2017] [Indexed: 12/22/2022]
Abstract
There are numerous profound maternal physiological changes that occur from conception onwards and adapt throughout gestation in order to support a healthy pregnancy. By the time of late gestation, when circulating pregnancy hormones are at their highest concentrations, maternal adaptations include relative hyperlipidemia, hypercholanemia and insulin resistance. Bile acids have now been established as key regulators of metabolism, and their role in gestational changes in metabolism is becoming apparent. Bile acid homeostasis is tightly regulated by the nuclear receptor FXR, which has been shown to have reduced activity during pregnancy. This review focuses on the gestational alterations in bile acid homeostasis that occur in normal pregnancy, which in some women can become pathological, leading to the development of intrahepatic cholestasis of pregnancy. As well as their important role in maternal metabolic health, we will review bile acid metabolism in the feto-placental unit.
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Affiliation(s)
- Saraid McIlvride
- Division of Women's Health, King's College London, Guy's Campus, Hodgkin Building, SE1 1UL, London, United Kingdom
| | - Peter H Dixon
- Division of Women's Health, King's College London, Guy's Campus, Hodgkin Building, SE1 1UL, London, United Kingdom
| | - Catherine Williamson
- Division of Women's Health, King's College London, Guy's Campus, Hodgkin Building, SE1 1UL, London, United Kingdom.
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28
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Intérêt des progestatifs dans la prévention de la prématurité spontanée. ACTA ACUST UNITED AC 2016; 45:1280-1298. [DOI: 10.1016/j.jgyn.2016.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 11/24/2022]
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Pařízek A, Dušková M, Vítek L, Šrámková M, Hill M, Adamcová K, Šimják P, Černý A, Kordová Z, Vráblíková H, Boudová B, Koucký M, Malíčková K, Stárka L. The role of steroid hormones in the development of intrahepatic cholestasis of pregnancy. Physiol Res 2016; 64:S203-9. [PMID: 26680481 DOI: 10.33549/physiolres.933117] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a disorder of liver function, commonly occurring in the third trimester but sometimes also as soon as the end of the second trimester of pregnancy. Symptoms of this disorder include pruritus, plus abnormal values of bile acids and hepatic transaminases. After birth, symptoms disappear and liver function returns to normal. Though ICP is relatively non-complicated and often symptomatically mild from the point-of-view of the mother, it presents a serious risk to the fetus, making this disease the subject of great interest. The etiology and pathogenesis of ICP is multifactorial and as yet not fully elucidated. Hormonal factors likely play a significant role, along with genetic as well as exogenous factors. Here we summarize the knowledge of changes in steroid hormones and their role in the development of intrahepatic cholestasis of pregnancy. In addition, we consider the role of exogenous factors as possible triggers of steroid hormone changes, the relationship between metabolic steroids and bile acids, as well as the combination of these factors in the development of ICP in predisposed pregnant women.
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Affiliation(s)
- A Pařízek
- Department of Obstetrics and Gynecology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic, Institute of Endocrinology, Prague, Czech Republic.
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30
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Huang GQ, Wang XD. New insights into diagnosis and treatment of intrahepatic cholestasis of pregnancy. Shijie Huaren Xiaohua Zazhi 2016; 24:3749-3756. [DOI: 10.11569/wcjd.v24.i26.3749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-specific disease, characterized by maternal pruritus and abnormal serum biochemistries in the late second and third trimester of pregnancy. The symptoms and abnormal biochemistries resolve rapidly after fetal delivery. As a diagnosis of exclusion, the diagnosis of ICP is based on unexplained pruritus with other causes and impaired liver function presenting with elevated serum liver transaminases and/or bile acids. It is considered as severe ICP when bile acid ≥ 40 μmol/L during pregnancy. The pathogenesis of ICP is still unclear. Adverse perinatal outcomes associated with ICP are focused on increased risk of preterm, meconium-stained amniotic fluid, and perinatal mortality. Unpredictable fetal hypoxia may result in intrauterine fetal death, fetal distress during birth and even stillbirth, and lead to an increase of iatrogenic preterm and cesarean section. The etiology and pathogenesis of fetal stress in ICP are not yet clarified, which may be associated with impaired infrastructure and decreased stress-compensatory in human utero-placental-fetal unit, and related with vascular constriction of chorionic veins and umbilical cord due to elevated bile acids in fetal serum and amniotic fluid. The essential measures of standard treatment of ICP include: (1) monitoring and evaluation of disease, uterine contraction and fetus; (2) prevention and treatment of uterine contraction; (3) treatment with ursodeoxycholic acid (500-1500 mg/d) alone or in combination with S-adenosylmehionine (800-1000 mg/d) or rifampicin (300-1200 mg/d) to promote drainage of bile acids; (4) promotion of fetal growth and lung development; (5) treatment with vitamin K1 before delivery to prevent maternal and fetal hemorrhage; (6) and timely termination of pregnancy. Gestational weeks, fetal condition and severity of disease need to be taken into account when obstetricians decide the time of termination. Elective early delivery is still an effective measure to avoid stillbirth during prolongation of gestational weeks.
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Siou K, Walmsley SL, Murphy KE, Raboud J, Loutfy M, Yudin MH, Silverman M, Ladhani NN, Serghides L. Progesterone supplementation for HIV-positive pregnant women on protease inhibitor-based antiretroviral regimens (the ProSPAR study): a study protocol for a pilot randomized controlled trial. Pilot Feasibility Stud 2016; 2:49. [PMID: 27965866 PMCID: PMC5153916 DOI: 10.1186/s40814-016-0087-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 07/26/2016] [Indexed: 12/04/2022] Open
Abstract
Background In Canada, the majority of HIV-positive pregnant women receive combination antiretroviral therapy that includes a ritonavir-boosted protease inhibitor to prevent mother-to-child HIV transmission. However, protease inhibitor-based combination antiretroviral therapy has been associated with increased rates of preterm, low birth weight, and small for gestational age births. Our previous experimental findings demonstrate that protease inhibitor use during pregnancy is associated with decreased progesterone levels that correlate with fetal growth, and that progesterone supplementation can improve protease inhibitor-induced fetal growth restriction. We hypothesize that HIV-positive pregnant women who receive protease inhibitor-based combination therapy may also benefit from progesterone supplementation during pregnancy. Methods/design In order to test this hypothesis, we have designed an open-label, multi-centre, randomized controlled (parallel group) pilot trial. The initial goal of this trial is to test feasibility and acceptability of our intervention. Forty HIV-positive pregnant women who are either on, or intending to start or switch to a boosted protease inhibitor-based combination antiretroviral regimen will be enrolled from six sites across Ontario, Canada. Twenty-five women will be randomized to self-administer natural progesterone (Prometrium, 200 mg) vaginally every night starting between gestational week 16 and 24 until week 36, and 15 women will be randomized to no intervention. While the participants and treating physicians will not be blinded, the laboratory personnel performing the biochemical and morphological evaluations will be blinded to ensure unbiased evaluation. The primary outcome of the pilot study is the feasibility of enrolment as measured by the recruitment rate and patient-reported reasons to decline participation. Secondary outcomes in participants include safety, acceptability, and adherence to progesterone supplementation. Discussion Given the safety of intravaginal progesterone and its current use in the general obstetrical population to prevent recurrent preterm delivery, this pilot study will provide data to determine the feasibility of a larger randomized controlled trial to assess the impact of this intervention on improving neonatal health in the context of HIV-positive pregnancies. Trial registration ClinicalTrials.gov, NCT02400021
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Affiliation(s)
- Kaitlin Siou
- Toronto General Research Institute, Toronto, Canada
| | - Sharon L Walmsley
- Toronto General Hospital, Toronto, Canada ; University of Toronto, Toronto, Canada
| | - Kellie E Murphy
- Mount Sinai Hospital, Toronto, Canada ; University of Toronto, Toronto, Canada
| | - Janet Raboud
- Toronto General Research Institute, Toronto, Canada
| | - Mona Loutfy
- Maple Leaf Medical Clinic, Toronto, Canada ; Women's College Research Institute, Toronto, Canada ; University of Toronto, Toronto, Canada
| | - Mark H Yudin
- St. Michael's Hospital, Toronto, Canada ; University of Toronto, Toronto, Canada
| | - Michael Silverman
- St. Joseph's Health Care London, London, Canada ; University of Western Ontario, London, Canada
| | - Noor N Ladhani
- Sunnybrook Health Sciences Centre, Toronto, Canada ; University of Toronto, Toronto, Canada
| | - Lena Serghides
- Toronto General Research Institute, Toronto, Canada ; University of Toronto, Toronto, Canada ; Women's College Research Institute, Toronto, Canada
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Pařízek A, Hill M, Dušková M, Vítek L, Velíková M, Kancheva R, Šimják P, Koucký M, Kokrdová Z, Adamcová K, Černý A, Hájek Z, Stárka L. A Comprehensive Evaluation of Steroid Metabolism in Women with Intrahepatic Cholestasis of Pregnancy. PLoS One 2016; 11:e0159203. [PMID: 27494119 PMCID: PMC4975406 DOI: 10.1371/journal.pone.0159203] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/28/2016] [Indexed: 12/27/2022] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a common liver disorder, mostly occurring in the third trimester. ICP is defined as an elevation of serum bile acids, typically accompanied by pruritus and elevated activities of liver aminotransferases. ICP is caused by impaired biliary lipid secretion, in which endogenous steroids may play a key role. Although ICP is benign for the pregnant woman, it may be harmful for the fetus. We evaluated the differences between maternal circulating steroids measured by RIA (17-hydroxypregnenolone and its sulfate, 17-hydroxyprogesterone, and cortisol) and GC-MS (additional steroids), hepatic aminotransferases and bilirubin in women with ICP (n = 15, total bile acids (TBA) >8 μM) and corresponding controls (n = 17). An age-adjusted linear model, receiver-operating characteristics (ROC), and multivariate regression (a method of orthogonal projections to latent structure, OPLS) were used for data evaluation. While aminotransferases, conjugates of pregnanediols, 17-hydroxypregnenolone and 5β-androstane-3α,17β-diol were higher in ICP patients, 20α-dihydropregnenolone, 16α-hydroxy-steroids, sulfated 17-oxo-C19-steroids, and 5β-reduced steroids were lower. The OPLS model including steroids measured by GC-MS and RIA showed 93.3% sensitivity and 100% specificity, while the model including steroids measured by GC-MS in a single sample aliquot showed 93.3% sensitivity and 94.1% specificity. A composite index including ratios of sulfated 3α/β-hydroxy-5α/β-androstane-17-ones to conjugated 5α/β-pregnane-3α/β, 20α-diols discriminated with 93.3% specificity and 81.3% sensitivity (ROC analysis). These new data demonstrating altered steroidogenesis in ICP patients offer more detailed pathophysiological insights into the role of steroids in the development of ICP.
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Affiliation(s)
- Antonín Pařízek
- Department of Obstetrics and Gynecology, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Martin Hill
- Institute of Endocrinology, Prague, Czech Republic
- * E-mail:
| | | | - Libor Vítek
- Institute of Medical Biochemistry and Laboratory Diagnostics and 4th Department of Internal Medicine, General University Hospital and 1st Faculty of Medicine of Charles University in Prague, Prague, Czech Republic
| | | | | | - Patrik Šimják
- Department of Obstetrics and Gynecology, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Michal Koucký
- Department of Obstetrics and Gynecology, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Zuzana Kokrdová
- Department of Obstetrics and Gynecology, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Karolína Adamcová
- Department of Obstetrics and Gynecology, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Andrej Černý
- Department of Obstetrics and Gynecology, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Zdeněk Hájek
- Department of Obstetrics and Gynecology, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
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Bile acids in drug induced liver injury: Key players and surrogate markers. Clin Res Hepatol Gastroenterol 2016; 40:257-266. [PMID: 26874804 DOI: 10.1016/j.clinre.2015.12.017] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 12/21/2015] [Accepted: 12/27/2015] [Indexed: 02/04/2023]
Abstract
Bile acid research has gained great momentum since the role of bile acids as key signaling molecules in the enterohepatic circulation was discovered. Their physiological function in regulating their own homeostasis, as well as energy and lipid metabolism make them interesting targets for the pharmaceutical industry in the context of diseases such as bile acid induced diarrhea, bile acid induced cholestasis or nonalcoholic steatohepatitis. Changes in bile acid homeostasis are also linked to various types of drug-induced liver injury (DILI). However, the key question whether bile acids are surrogate markers for monitoring DILI or key pathogenic players in the onset and progression of DILI is under intense investigation. The purpose of this review is to summarize the different facets of bile acids in the context of normal physiology, hereditary defects of bile acid transport and DILI.
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Abu‐Hayyeh S, Ovadia C, Lieu T, Jensen DD, Chambers J, Dixon PH, Lövgren‐Sandblom A, Bolier R, Tolenaars D, Kremer AE, Syngelaki A, Noori M, Williams D, Marin JJ, Monte MJ, Nicolaides KH, Beuers U, Oude‐Elferink R, Seed PT, Chappell L, Marschall H, Bunnett NW, Williamson C. Prognostic and mechanistic potential of progesterone sulfates in intrahepatic cholestasis of pregnancy and pruritus gravidarum. Hepatology 2016; 63:1287-98. [PMID: 26426865 PMCID: PMC4869673 DOI: 10.1002/hep.28265] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/28/2015] [Indexed: 12/17/2022]
Abstract
UNLABELLED A challenge in obstetrics is to distinguish pathological symptoms from those associated with normal changes of pregnancy, typified by the need to differentiate whether gestational pruritus of the skin is an early symptom of intrahepatic cholestasis of pregnancy (ICP) or due to benign pruritus gravidarum. ICP is characterized by raised serum bile acids and complicated by spontaneous preterm labor and stillbirth. A biomarker for ICP would be invaluable for early diagnosis and treatment and to enable its differentiation from other maternal diseases. Three progesterone sulfate compounds, whose concentrations have not previously been studied, were newly synthesized and assayed in the serum of three groups of ICP patients and found to be significantly higher in ICP at 9-15 weeks of gestation and prior to symptom onset (group 1 cases/samples: ICP n = 35/80, uncomplicated pregnancy = 29/100), demonstrating that all three progesterone sulfates are prognostic for ICP. Concentrations of progesterone sulfates were associated with itch severity and, in combination with autotaxin, distinguished pregnant women with itch that would subsequently develop ICP from pruritus gravidarum (group 2: ICP n = 41, pruritus gravidarum n = 14). In a third group of first-trimester samples all progesterone sulfates were significantly elevated in serum from low-risk asymptomatic women who subsequently developed ICP (ICP/uncomplicated pregnancy n = 54/51). Finally, we show mechanistically that progesterone sulfates mediate itch by evoking a Tgr5-dependent scratch response in mice. CONCLUSION Our discovery that sulfated progesterone metabolites are a prognostic indicator for ICP will help predict onset of ICP and distinguish it from benign pruritus gravidarum, enabling targeted obstetric care to a high-risk population. Delineation of a progesterone sulfate-TGR5 pruritus axis identifies a therapeutic target for itch management in ICP.
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Affiliation(s)
- Shadi Abu‐Hayyeh
- Women's Health Academic CentreKing's College LondonLondonUnited Kingdom
| | - Caroline Ovadia
- Women's Health Academic CentreKing's College LondonLondonUnited Kingdom
| | - TinaMarie Lieu
- Monash Institute of Pharmaceutical Sciences and Australian Research Council Centre of Excellence in Convergent Bio‐Nano Science and TechnologyMonash UniversityParkvilleVictoriaAustralia
| | - Dane D. Jensen
- Monash Institute of Pharmaceutical Sciences and Australian Research Council Centre of Excellence in Convergent Bio‐Nano Science and TechnologyMonash UniversityParkvilleVictoriaAustralia
| | - Jenny Chambers
- Women's Health Academic CentreKing's College LondonLondonUnited Kingdom
- Institute of Reproductive and Developmental BiologyImperial College LondonLondonUnited Kingdom
| | - Peter H. Dixon
- Women's Health Academic CentreKing's College LondonLondonUnited Kingdom
- Institute of Reproductive and Developmental BiologyImperial College LondonLondonUnited Kingdom
| | | | - Ruth Bolier
- Tytgat Institute for Liver and Intestinal ResearchAcademic Medical CentreAmsterdamThe Netherlands
| | - Dagmar Tolenaars
- Tytgat Institute for Liver and Intestinal ResearchAcademic Medical CentreAmsterdamThe Netherlands
| | - Andreas E. Kremer
- Tytgat Institute for Liver and Intestinal ResearchAcademic Medical CentreAmsterdamThe Netherlands
- Department of Medicine 1Friedrich‐Alexander‐University of Erlangen‐NurembergErlangenGermany
| | - Argyro Syngelaki
- Harris Birthright Research Centre for Fetal MedicineKing's College HospitalLondonUnited Kingdom
| | - Muna Noori
- Institute of Reproductive and Developmental BiologyImperial College LondonLondonUnited Kingdom
| | - David Williams
- Institute for Women's HealthUniversity College London HospitalsLondonUnited Kingdom
| | - Jose J.G. Marin
- Laboratory of Experimental Hepatology and Drug Targeting (HEVEFARM), Biomedical Research Institute of Salamanca (IBSAL)University of Salamanca, National Institute for the Study of Liver and Gastrointestinal Diseases (CIBERehd)SalamancaSpain
| | - Maria J. Monte
- Laboratory of Experimental Hepatology and Drug Targeting (HEVEFARM), Biomedical Research Institute of Salamanca (IBSAL)University of Salamanca, National Institute for the Study of Liver and Gastrointestinal Diseases (CIBERehd)SalamancaSpain
| | - Kypros H. Nicolaides
- Harris Birthright Research Centre for Fetal MedicineKing's College HospitalLondonUnited Kingdom
| | - Ulrich Beuers
- Tytgat Institute for Liver and Intestinal ResearchAcademic Medical CentreAmsterdamThe Netherlands
| | - Ronald Oude‐Elferink
- Tytgat Institute for Liver and Intestinal ResearchAcademic Medical CentreAmsterdamThe Netherlands
| | - Paul T. Seed
- Women's Health Academic CentreKing's College LondonLondonUnited Kingdom
| | - Lucy Chappell
- Women's Health Academic CentreKing's College LondonLondonUnited Kingdom
| | - Hanns‐Ulrich Marschall
- Institute of Medicine, Department of Molecular and Clinical MedicineUniversity of GothenburgGothenburgSweden
| | - Nigel W. Bunnett
- Monash Institute of Pharmaceutical Sciences and Australian Research Council Centre of Excellence in Convergent Bio‐Nano Science and TechnologyMonash UniversityParkvilleVictoriaAustralia
- Department of PharmacologyUniversity of MelbourneParkvilleVictoriaAustralia
| | - Catherine Williamson
- Women's Health Academic CentreKing's College LondonLondonUnited Kingdom
- Institute of Reproductive and Developmental BiologyImperial College LondonLondonUnited Kingdom
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Dixon PH, Williamson C. The pathophysiology of intrahepatic cholestasis of pregnancy. Clin Res Hepatol Gastroenterol 2016; 40:141-53. [PMID: 26823041 DOI: 10.1016/j.clinre.2015.12.008] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 12/02/2015] [Accepted: 12/10/2015] [Indexed: 02/06/2023]
Abstract
A number of liver disorders are specific to pregnancy. Amongst these, intrahepatic cholestasis of pregnancy (ICP), also known as obstetric cholestasis (OC), is the commonest, affecting approximately 1 in 140 UK pregnancies. Patients commonly present in the third trimester with severe pruritus and deranged serum liver tests; bile acids are elevated, in severe cases >40 μmol/L. Although the disease is considered relatively benign for the mother, increased rates of adverse fetal outcomes, including stillbirth, are associated with ICP. As our knowledge of the mechanisms underlying bile acid homeostasis has advanced in the last 15 years our understanding of ICP has grown, in particular with respect to genetic influences on susceptibility to the disease, the role of reproductive hormones and their metabolites and the possible identity of the pruritic agents. In this review, we will describe recent advances in the understanding of this condition with a particular emphasis on how aspects of genetic and reproductive hormone involvement in pathophysiology have been elucidated. We also review recent developments regarding our knowledge of placental and fetal pathophysiology and the long-term health consequences for the mother and child.
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Affiliation(s)
- Peter H Dixon
- Division of Women's Health, 2.30W Hodgkin Building, King's College London, Guy's Campus, SE1 1UL London, United Kingdom
| | - Catherine Williamson
- Division of Women's Health, 2.30W Hodgkin Building, King's College London, Guy's Campus, SE1 1UL London, United Kingdom.
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Abstract
Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a pruritic condition of pregnancy characterized by an underlying elevation in circulating bile acids and liver derangement, and associated with adverse fetal outcomes, such as preterm labor and stillbirth. Limited understanding of the underlying pathophysiology and mechanisms involved in adverse outcomes has previously restricted treatment options and pregnancy management. Recent advances in these research fields provide tantalizing targets to improve the care of pregnant women affected by this condition.
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Affiliation(s)
- Caroline Ovadia
- Women's Health Academic Centre, King's College London, London, United Kingdom
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Telbisz Á, Homolya L. Recent advances in the exploration of the bile salt export pump (BSEP/ABCB11) function. Expert Opin Ther Targets 2015; 20:501-14. [PMID: 26573700 DOI: 10.1517/14728222.2016.1102889] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The bile salt export pump (BSEP/ABCB11), residing in the apical membrane of hepatocyte, mediates the secretion of bile salts into the bile. A range of human diseases is associated with the malfunction of BSEP, including fatal hereditary liver disorders and mild cholestatic conditions. Manifestation of these diseases primarily depends on the mutation type; however, other factors such as hormonal changes and drug interactions can also trigger or influence the related diseases. AREAS COVERED Here, we summarize the recent knowledge on BSEP by covering its transport properties, cellular localization, regulation and major mutations/polymorphisms, as well as the hereditary and acquired diseases associated with BSEP dysfunction. We discuss the different model expression systems employed to understand the function of the BSEP variants, their drug interactions and the contemporary therapeutic interventions. EXPERT OPINION The limitations of the available model expression systems for BSEP result in controversial conclusions, and obstruct our deeper insight into BSEP deficiencies and BSEP-related drug interactions. The knowledge originating from different methodologies, such as clinical studies, molecular genetics, as well as in vitro and in silico modeling, should be integrated and harmonized. Increasing availability of robust molecular biological tools and our better understanding of the mechanism of BSEP deficiencies should make the personalized, mutation-based therapeutic interventions more attainable.
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Affiliation(s)
- Ágnes Telbisz
- a Institute of Enzymology, Research Centre for Natural Sciences , Hungarian Academy of Sciences , Magyar tudósok körútja 2, Budapest 1117 , Hungary
| | - László Homolya
- a Institute of Enzymology, Research Centre for Natural Sciences , Hungarian Academy of Sciences , Magyar tudósok körútja 2, Budapest 1117 , Hungary
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38
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Larson SP, Kovilam O, Agrawal DK. Immunological basis in the pathogenesis of intrahepatic cholestasis of pregnancy. Expert Rev Clin Immunol 2015; 12:39-48. [PMID: 26469633 DOI: 10.1586/1744666x.2016.1101344] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Intrahepatic cholestasis of pregnancy poses a great risk to both maternal and fetal health. Despite extensive research, much of the pathogenesis of this disorder is unknown. The increase in bile acids observed in patients with intrahepatic cholestasis of pregnancy has been noted to cause a change in the immune system from the normally mediated TH2 response to one that is more oriented towards TH1. In this literature review, we have critically reviewed the current literature regarding the changes in the immune system and the potential effects of immunological changes in the management of the patient. The current treatment, ursodeoxycholic acid, is also discussed along with potential combination therapies and future directions for research.
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Affiliation(s)
- Spencer P Larson
- a Center for Clinical & Translational Science , Creighton University School of Medicine , Omaha , NE , USA.,b Department of Obstetrics and Gynecology , Creighton University School of Medicine , Omaha , NE , USA
| | - Oormila Kovilam
- b Department of Obstetrics and Gynecology , Creighton University School of Medicine , Omaha , NE , USA
| | - Devendra K Agrawal
- a Center for Clinical & Translational Science , Creighton University School of Medicine , Omaha , NE , USA
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Estiú MC, Monte MJ, Rivas L, Moirón M, Gomez-Rodriguez L, Rodriguez-Bravo T, Marin JJG, Macias RIR. Effect of ursodeoxycholic acid treatment on the altered progesterone and bile acid homeostasis in the mother-placenta-foetus trio during cholestasis of pregnancy. Br J Clin Pharmacol 2015; 79:316-29. [PMID: 25099365 DOI: 10.1111/bcp.12480] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AIM Intrahepatic cholestasis of pregnancy (ICP) is characterized by pruritus and elevated bile acid concentrations in maternal serum. This is accompanied by an enhanced risk of intra-uterine and perinatal complications. High concentrations of sulphated progesterone metabolites (PMS) have been suggested to be involved in the multifactorial aetiopathogenesis of ICP. The aim of this study was to investigate further the mechanism accounting for the beneficial effect of oral administration of ursodeoxycholic acid (UDCA), which is the standard treatment, regarding bile acid and PMS homeostasis in the mother-placenta-foetus trio. METHOD Using HPLC-MS/MS bile acids and PMS were determined in maternal and foetal serum and placenta. The expression of ABC proteins in placenta was determined by real time quantitative PCR (RT-QPCR) and immunofluorescence. RESULTS In ICP, markedly increased concentrations of bile acids (tauroconjugates > glycoconjugates >> unconjugated), progesterone and PMS in placenta and maternal serum were accompanied by enhanced concentrations in foetal serum of bile acids, but not of PMS. UDCA treatment reduced bile acid accumulation in the mother-placenta-foetus trio, but had no significant effect on progesterone and PMS concentrations. ABCG2 mRNA abundance was increased in placentas from ICP patients vs. controls and remained stable following UDCA treatment, despite an apparent further increase in ABCG2. CONCLUSION UDCA administration partially reduces ICP-induced bile acid accumulation in mothers and foetuses despite the lack of effect on concentrations of progesterone and PMS in maternal serum. Up-regulation of placental ABCG2 may play an important role in protecting the foetus from high concentrations of bile acids and PMS during ICP.
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Affiliation(s)
- Maria C Estiú
- Ramón Sardá Mother' and Children's Hospital, Buenos Aires, Argentina
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Abstract
Sulfated progesterone metabolites rise 100-fold in the third trimester of human pregnancy and have been shown to be elevated further in the gestational disorder intrahepatic cholestasis of pregnancy (ICP). Typical concentrations of progesterone sulfates range from 1 to 10 µmol/L in an uncomplicated pregnancy and rise to approximately 40 µmol/L in ICP. At this level they can influence bile acid and lipid metabolism. Studies using human and rodent specimens have shown that sulfated metabolites of progesterone competitively inhibit bile acid homeostasis pathways by functioning as partial agonists of farnesoid X receptor (FXR). This explains the loss of induction of FXR target genes in ICP, and may explain susceptibility to hypercholanaemia and dyslipidaemia in the second half of human pregnancy. Furthermore, progesterone sulfates are competitive inhibitors of biliary influx (NTCP) and efflux (BSEP) transport proteins, actions likely to further exacerbate hypercholanaemia and cholestasis.
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Affiliation(s)
- Shadi Abu-Hayyeh
- Women's Health Academic Centre, Kings College London, London, UK
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42
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Zhang XQ, Zhang LJ, Yang WH, Draper ML. Effect of the maternal-fetal interface immunoregulation on the occurrence of intrahepatic cholestasis of pregnancy. World J Obstet Gynecol 2015; 4:40-45. [DOI: 10.5317/wjog.v4.i2.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 01/14/2015] [Accepted: 02/02/2015] [Indexed: 02/05/2023] Open
Abstract
Maternal immune tolerance of the fetus is indispensable for a healthy pregnancy. Currently, the study of the immune microenvironment of the maternal-fetal interface has been a heated topic in reproductive immunology research. More and more studies show that the immune imbalance in the maternal-fetal interface plays a very important role in the incidence of intrahepatic cholestasis of pregnancy (ICP). However, the precise etiology and mechanism of immune imbalance in the occurrence of ICP is still unknown. In order to clarify the potential immunologic mechanisms of ICP, this review summarizes the recent studies of the decidual immunology microenvironment and the potential immunologic mechanisms related to the development of ICP.
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Kubitz R, Dröge C, Kluge S, Stindt J, Häussinger D. Genetic variations of bile salt transporters. DRUG DISCOVERY TODAY. TECHNOLOGIES 2015; 12:e55-67. [PMID: 25027376 DOI: 10.1016/j.ddtec.2014.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Bile salt transporters directly or indirectly influence biological processes through physicochemical or signalling properties of bile salts. The coordinated action of uptake and efflux transporters in polarized epithelial cells of the liver, biliary tree, small intestine and kidney determine bile salt concentrations in different compartments of the body. Genetic variations of bile salt transporters lead to clinical relevant phenotypes of varying severity ranging from a predisposition for drug-induced liver injury to rapidly progressing end-stage liver disease. This review focuses on the impact of genetic variations of bile salt transporters including BSEP, NTCP, ASBT and OSTα/β and discusses approaches for transporter analysis.
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Abu-Hayyeh S, Williamson C. Estradiol, farnesoid X receptor, and altered metabolism in pregnancy. Hepatology 2014; 60:1815-7. [PMID: 24975680 DOI: 10.1002/hep.27280] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 06/24/2014] [Indexed: 12/19/2022]
Affiliation(s)
- Shadi Abu-Hayyeh
- Women's Health Academic Centre, Kings College London, Guy's Campus, London, UK
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45
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Dietrich CG, Geier A. Effect of drug transporter pharmacogenetics on cholestasis. Expert Opin Drug Metab Toxicol 2014; 10:1533-51. [PMID: 25260651 DOI: 10.1517/17425255.2014.963553] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The liver is the central place for the metabolism of drugs and other xenobiotics. In the liver cell, oxidation and conjugation of compounds take place, and at the same time, bile formation helps in extrusion of these compounds via the biliary route. A large number of transporters are responsible for drug uptake into the liver cell and excretion into bile or efflux to the sinusoidal blood. AREAS COVERED Genetic variants of these transporters and their transactivators contribute to changes in drug handling and are also responsible for cholestatic syndromes of different severity. This review summarizes the current knowledge regarding the influence of these genetic changes. The review covers progressive hereditary cholestatic syndromes as well as recurrent or transient cholestatic syndromes such as drug-induced liver injury, intrahepatic cholestasis of pregnancy, and benign recurrent intrahepatic cholestasis. EXPERT OPINION Polymorphisms in transporter genes are frequent. For clinically relevant cholestatic syndromes, it often requires a combination of genetic variants or acquired triggers such as pregnancy or drug treatment. In combination with other pathogenetic aspects, genetic variants in drug transporters may contribute to our understanding of not only cholestatic diseases such as primary sclerosing cholangitis or primary biliary cirrhosis, but also the natural course of chronic liver disease in general.
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Johnston RC, Stephenson ML, Nageotte MP. Novel heterozygous ABCB4 gene mutation causing recurrent first-trimester intrahepatic cholestasis of pregnancy. J Perinatol 2014; 34:711-2. [PMID: 25179380 DOI: 10.1038/jp.2014.86] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 02/27/2014] [Accepted: 03/24/2014] [Indexed: 01/24/2023]
Abstract
Intrahepatic cholestasis of pregnancy (ICP) typically presents in the late second or third trimester and carries an increased risk of fetal demise and neonatal morbidity and mortality. First trimester onset is rare and should alert the physician to explore a possible genetic basis for the disease. We present a 26-year-old Hispanic gravida 3, para 0202 with recurrent first-trimester onset ICP. Given her atypical history and presentation, a genetic cause was considered. She was found to have a novel heterozygous missense mutation in the ABCB4 canalicular membrane transport gene. First or early second trimester presentation of ICP should prompt investigation into genetic causes of the disease. Individualized family counseling and neonatal evaluation should be addressed if a disease-causing genetic mutation is diagnosed.
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Affiliation(s)
- R C Johnston
- 1] Department of Obstetrics and Gynecology, University of California Irvine Medical Center, Orange, CA, USA [2] Miller Children's Hospital/Long Beach Memorial Medical Center, Long Beach, CA, USA
| | - M L Stephenson
- 1] Department of Obstetrics and Gynecology, University of California Irvine Medical Center, Orange, CA, USA [2] Miller Children's Hospital/Long Beach Memorial Medical Center, Long Beach, CA, USA
| | - M P Nageotte
- 1] Department of Obstetrics and Gynecology, University of California Irvine Medical Center, Orange, CA, USA [2] Miller Children's Hospital/Long Beach Memorial Medical Center, Long Beach, CA, USA
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Ritschel T, Hermans SMA, Schreurs M, van den Heuvel JJMW, Koenderink JB, Greupink R, Russel FGM. In silico identification and in vitro validation of potential cholestatic compounds through 3D ligand-based pharmacophore modeling of BSEP inhibitors. Chem Res Toxicol 2014; 27:873-81. [PMID: 24713091 DOI: 10.1021/tx5000393] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Drug-induced cholestasis is a frequently observed side effect of drugs and is often caused by an unexpected interaction with the bile salt export pump (BSEP/ABCB11). BSEP is the key membrane transporter responsible for the transport of bile acids from hepatocytes into bile. Here, we developed a pharmacophore model that describes the molecular features of compounds associated with BSEP inhibitory activity. To generate input and validation data sets, in vitro experiments with membrane vesicles overexpressing human BSEP were used to assess the effect of compounds (50 μM) on BSEP-mediated (3)H-taurocholic acid transport. The model contains two hydrogen bond acceptor/anionic features, two hydrogen bond acceptor vector features, four hydrophobic/aromatic features, and exclusion volumes. The pharmacophore was validated against a set of 59 compounds, including registered drugs. The model recognized 9 out of 12 inhibitors (75%), which could not be identified based on general parameters, such as molecular weight or SlogP, alone. Finally, the model was used to screen a virtual compound database. A number of compounds found via virtual screening were tested and displayed statistically significant BSEP inhibition, ranging from 13 ± 1% to 67 ± 7% of control (P < 0.05). In conclusion, we developed and validated a pharmacophore model that describes molecular features found in BSEP inhibitors. The model may be used as an in silico screening tool to identify potentially harmful drug candidates at an early stage in drug development.
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Affiliation(s)
- Tina Ritschel
- Computational Discovery and Design (CDD) Group, Centre for Molecular and Biomolecular Informatics (CMBI), Radboud university medical center , P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Pfeifer ND, Hardwick RN, Brouwer KLR. Role of hepatic efflux transporters in regulating systemic and hepatocyte exposure to xenobiotics. Annu Rev Pharmacol Toxicol 2013; 54:509-35. [PMID: 24160696 DOI: 10.1146/annurev-pharmtox-011613-140021] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Hepatic efflux transporters include numerous well-known and emerging proteins localized to the canalicular or basolateral membrane of the hepatocyte that are responsible for the excretion of drugs into the bile or blood, respectively. Altered function of hepatic efflux transporters due to drug-drug interactions, genetic variation, and/or disease states may lead to changes in xenobiotic exposure in the hepatocyte and/or systemic circulation. This review focuses on transport proteins involved in the hepatocellular efflux of drugs and metabolites, discusses mechanisms of altered transporter function as well as the interplay between multiple transport pathways, and highlights the importance of considering intracellular unbound concentrations of transporter substrates and/or inhibitors. Methods to evaluate hepatic efflux transport and predict the effects of impaired transporter function on systemic and hepatocyte exposure are discussed, and the sandwich-cultured hepatocyte model to evaluate comprehensively the role of hepatic efflux in the hepatobiliary disposition of xenobiotics is characterized.
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Affiliation(s)
- Nathan D Pfeifer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599; ,
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Keitel V, Spomer L, Marin J, Williamson C, Geenes V, Kubitz R, Häussinger D, Macias R. Effect of maternal cholestasis on TGR5 expression in human and rat placenta at term. Placenta 2013; 34:810-6. [DOI: 10.1016/j.placenta.2013.06.302] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 05/31/2013] [Accepted: 06/18/2013] [Indexed: 01/26/2023]
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Zhu QN, Xie HM, Zhang D, Liu J, Lu YF. Hepatic bile acids and bile acid-related gene expression in pregnant and lactating rats. PeerJ 2013; 1:e143. [PMID: 24010021 PMCID: PMC3757468 DOI: 10.7717/peerj.143] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 08/05/2013] [Indexed: 01/28/2023] Open
Abstract
Background. Significant physiological changes occur during pregnancy and lactation. Intrahepatic cholestasis of pregnancy (ICP) is a liver disease closely related to disruption of bile acid homeostasis. The objective of this study was to examine the regulation of bile acid synthesis and transport in normal pregnant and lactating rats. Materials and Methods. Livers from timed pregnant SD rats were collected on gestational days (GD) 10, 14 and 19, and postnatal days (PND) 1, 7, 14 and 21. Total bile acids were determined by the enzymatic method, total RNA was isolated and subjected to real time RT-PCR analysis. Liver protein was extracted for western-blot analysis. Results. Under physiological conditions hepatic bile acids were not elevated during pregnancy but increased during lactation in rats. Bile acid synthesis rate-limiting enzyme Cyp7a1 was unchanged on gestational days, but increased on PND14 and 21 at mRNA and protein levels. Expression of Cyp8b1, Cyp27a1 and Cyp7b1 was also higher during lactation. The mRNA levels of small heterodimer partner (SHP) and protein levels of farnesoid X receptor (FXR) were increased during pregnancy and lactation. Bile acid transporters Ntcp, Bsep, Mrp3 and Mrp4 were lower at gestation, but increased during lactation. Hepatic Oatp transporters were decreased during pregnancy and lactation. Conclusion. Hepatic bile acid homeostasis is maintained during normal pregnancy in rats, probably through the FXR-SHP regulation. The expression of bile acid synthesis genes and liver bile acid accumulation were increased during lactation, together with increased expression of bile acid efflux transporter Bsep, Mrp3 and Mrp4.
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Affiliation(s)
- Qiong N Zhu
- Department of Pharmacology and Key Lab of Basic Pharmacology of Guizhou, Zunyi Medical College , Zunyi , China
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