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Anim M, Sogkas G, Camacho-Ordonez N, Schmidt G, Elsayed A, Proietti M, Witte T, Grimbacher B, Atschekzei F. Novel hypermorphic variants in IRF2BP2 identified in patients with common variable immunodeficiency and autoimmunity. Clin Immunol 2024; 266:110326. [PMID: 39059757 DOI: 10.1016/j.clim.2024.110326] [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: 06/03/2024] [Revised: 07/12/2024] [Accepted: 07/21/2024] [Indexed: 07/28/2024]
Abstract
The interferon regulatory factor 2 binding protein 2 (IRF2BP2) is a transcriptional regulator, functioning a transcriptional corepressor by interacting with the interferon regulatory factor-2. The ubiquitous expression of IRF2BP2 by diverse cell types and tissues suggests its potential involvement in different cell signalling pathways. Variants inIRF2BP2have been recently identified to cause familial common variable immunodeficiency (CVID) characterized by immune dysregulation. This study investigated three rare novel variants inIRF2BP2, identified in patients with primary antibody deficiency and autoimmunity by whole exome-sequencing (WES). Following transient overexpression of EGFP-fused mutants in HEK293 cells and transfection in Jurkat cell lines, we used fluorescence microscopy, real-time PCR and Western blotting to analyze their effects on IRF2BP2 expression, subcellular localization, nuclear translocation of IRF2, and the transcriptional activation of NFκB1(p50). We found altered IRF2BP2 mRNA and protein expression levels in the mutants compared to the wild type after IRF2BP2 overexpression. In confocal fluorescence microscopy, variants in the C-terminal RING finger domain showed an irregular aggregate formation and distribution instead of the expected nuclear localization compared to the variants in the N-terminal zinc finger domain and their wildtype counterpart. Immunoblotting revealed an impaired IRF2 and NFκB1 (p50) nuclear localization in the mutants compared to the IRF2BP2 wildtype counterpart. LPS stimulation reduced IRF2BP2 mRNA expression in the variants compared to the wild type. Our findings significantly contribute to understanding the clinical significance of IRF2BP2 mutations in the pathogenesis of immunodeficiency and immune dysregulation. We observed impairment of the nuclear translocation of IRF2 and NFκB1 (p50) due to the upregulation of IRF2BP2, potentially affecting specific gene expressions involved in immune regulation.
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Affiliation(s)
- Manfred Anim
- Department of Rheumatology and Immunology, Hannover Medical School, Hannover, Germany; Hannover Biomedical Research School (HBRS), Hannover Medical School, Hanover, Germany
| | - Georgios Sogkas
- Department of Rheumatology and Immunology, Hannover Medical School, Hannover, Germany; RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Hanover, Germany
| | - Nadezhda Camacho-Ordonez
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Faculty of Biology, University of Freiburg, Freiburg, Germany; Clinic of Rheumatology and Clinical Immunology, Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany
| | - Gunnar Schmidt
- Department of Human Genetics, Hannover Medical School, Hannover, Germany
| | - Abdulwahab Elsayed
- Department of Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
| | - Michele Proietti
- Department of Rheumatology and Immunology, Hannover Medical School, Hannover, Germany; RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Hanover, Germany.; Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Torsten Witte
- Department of Rheumatology and Immunology, Hannover Medical School, Hannover, Germany; RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Hanover, Germany
| | - Bodo Grimbacher
- RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Hanover, Germany.; Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Clinic of Rheumatology and Clinical Immunology, Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany; DZIF - German Center for Infection Research, Satellite Center Freiburg, Germany
| | - Faranaz Atschekzei
- Department of Rheumatology and Immunology, Hannover Medical School, Hannover, Germany; RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Hanover, Germany..
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Premkumar M, Anand AC. Porto-sinusoidal Vascular Disease: Classification and Clinical Relevance. J Clin Exp Hepatol 2024; 14:101396. [PMID: 38601747 PMCID: PMC11001647 DOI: 10.1016/j.jceh.2024.101396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/05/2024] [Indexed: 04/12/2024] Open
Abstract
Non-cirrhotic portal hypertension (NCPH) is a well-recognized clinico-pathological entity, which is associated with clinical signs and symptoms, imaging, and endoscopic features of portal hypertension (PHT), in absence of cirrhosis. In patients with NCPH without known risk factors of PHT or extrahepatic portal vein thrombosis, the condition is called idiopathic non-cirrhotic portal hypertension (INCPH). There are multiple infectious, immune related causes, systemic diseases, drug and toxin exposures, haematological disorders, and metabolic risk factors that have been associated with this INCPH. However, the causal pathogenesis is still unclear. The Vascular liver disorders interest group group recently proposed porto-sinusoidal vascular disease (PSVD) as a syndromic entity, which provides definite histopathological criteria for diagnosis of NCPH (table 1). The three classical histo-morphological lesions specific for PSVD include obliterative portal venopathy, nodular regenerative hyperplasia, and incomplete septal fibrosis. The PSVD definition includes patients with portal vein thrombosis, PVT, and even those without PHT, thus broadening the scope of diagnosis to include patients who may have presented early, prior to haemodynamic changes consistent with PHT. However, this new diagnosis has pros and cons. The cons include mandating invasive liver biopsy to assess the PSVD histological triad in all patients with NCPH, an erstwhile clinical diagnosis in Asian patients. In addition, the natural history of the subclinical forms of PSVD without PHT and linear progression to develop PHT is unknown yet. In this review, we discuss the diagnosis and treatment of INCPH/PSVD, fallacies and strengths of the old and new schema, pathobiology of this disease, and clinical correlates in an Asian context. Although formulation of standardised diagnostic criteria is useful for comparison of clinical cohorts with INCPH/PSVD, prospective clinical validation in global cohorts is necessary to avoid misclassification of vascular disorders of the liver.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Anil C. Anand
- Department of Hepatology, Kalinga Institute of Medical Sciences, Bhubaneshwar, Odisha, India
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Hercun J, Asif B, Vittal A, Ahmed A, Gopalakrishna Pillai HK, Bergerson JRE, Holland S, Uzel G, Strober W, Fuss IJ, Koh C, Kleiner DE, Heller T. Development of hepatic fibrosis in common variable immunodeficiency-related porto-sinusoidal vascular disorder. Aliment Pharmacol Ther 2024. [PMID: 39090843 DOI: 10.1111/apt.18180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/03/2024] [Accepted: 07/13/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND AND AIMS Liver involvement is an increasingly recognised complication of common variable immunodeficiency (CVID). Nodular regenerative hyperplasia (NRH), a subgroup of porto-sinusoidal vascular disorder, and manifestations of portal hypertension (PH) unrelated to cirrhosis are the most common findings. Nonetheless, the evolution of liver disease over time remains unknown. METHODS Retrospective review of patients followed at the National Institutes of Health with CVID-related liver disease and liver biopsy from 1990 to 2020. Clinical, imaging and histological follow-up were recorded as part of clinical research protocols. RESULTS Forty patients were included, with a median age of 37.5 years at initial biopsy, 73% presenting with clear evidence of NRH, and a median fibrosis stage of 1. At biopsy, median platelet count was 100 × 109/L, spleen size 19.5 cm, hepatic venous pressure gradient 9.5 mmHg and 37.5% of patients had signs of PH. Cumulative incidence of PH was 65% at 5 years. In a subgroup of 16 patients, a follow-up liver biopsy, performed at a median time of 3 years after the index biopsy, revealed an increase in fibrosis by ≥2 stages in 31% of cases and an increase to an overall stage of 2.2 (p = 0.001). No clinical or histological factors were associated with progression of fibrosis. CONCLUSIONS In this CVID cohort, NRH is the most common initial histological finding; however, unexpectedly fibrosis progresses over time in a subgroup of patients. A better understanding of the underlying causal process of liver disease CVID might lead to improved outcomes.
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Affiliation(s)
- Julian Hercun
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Bilal Asif
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Anusha Vittal
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Abdel Ahmed
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Harish Kumar Gopalakrishna Pillai
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Jenna R E Bergerson
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Steven Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Gulbu Uzel
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Warren Strober
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Ivan J Fuss
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Christopher Koh
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Theo Heller
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
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Ganapathi L, Cochran RL, Robbins GK, Barmettler S, Holland SM, Ababneh EI. Case 20-2024: A 73-Year-Old Man with Recurrent Fever and Liver Lesions. N Engl J Med 2024; 390:2309-2319. [PMID: 38924735 DOI: 10.1056/nejmcpc2309383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Affiliation(s)
- Lakshmi Ganapathi
- From the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Massachusetts General Hospital, and the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Harvard Medical School - both in Boston; and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (S.M.H.)
| | - Rory L Cochran
- From the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Massachusetts General Hospital, and the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Harvard Medical School - both in Boston; and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (S.M.H.)
| | - Gregory K Robbins
- From the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Massachusetts General Hospital, and the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Harvard Medical School - both in Boston; and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (S.M.H.)
| | - Sara Barmettler
- From the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Massachusetts General Hospital, and the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Harvard Medical School - both in Boston; and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (S.M.H.)
| | - Steven M Holland
- From the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Massachusetts General Hospital, and the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Harvard Medical School - both in Boston; and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (S.M.H.)
| | - Emad I Ababneh
- From the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Massachusetts General Hospital, and the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Harvard Medical School - both in Boston; and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (S.M.H.)
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Téllez L, Donate J, Albillos A. [Portosinusoidal vascular disorder: A paradigm shift]. Med Clin (Barc) 2024; 162:439-447. [PMID: 38302397 DOI: 10.1016/j.medcli.2023.11.018] [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: 09/24/2023] [Revised: 11/11/2023] [Accepted: 11/13/2023] [Indexed: 02/03/2024]
Abstract
The term portosinusoidal vascular disorder (PSVD) refers to a clinical-pathological entity that encompasses those patients with intrahepatic vascular damage without cirrhosis at risk of developing severe complications of portal hypertension. Numerous systemic diseases, genetic disorders, and toxic agents have been associated with this pathology, making its diagnosis an important clinical challenge. The recent description of uniform diagnostic criteria and a better understanding of its pathophysiology will allow for better identification of patients, even in early stages of the disease. Although there is currently no effective etiological treatment available, early diagnosis allows for the development of preventive strategies for some severe complications of portal hypertension.
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Affiliation(s)
- Luis Téllez
- Servicio de Gastroenterología y Hepatología. Hospital Universitario Ramón y Cajal, Madrid, España; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, España; Centro de Investigación en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, España; Universidad de Alcalá, Madrid, España.
| | - Jesús Donate
- Servicio de Gastroenterología y Hepatología. Hospital Universitario Ramón y Cajal, Madrid, España
| | - Agustín Albillos
- Servicio de Gastroenterología y Hepatología. Hospital Universitario Ramón y Cajal, Madrid, España; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, España; Centro de Investigación en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, España; Universidad de Alcalá, Madrid, España
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Mironova M, Gopalakrishna H, Rodriguez Franco G, Holland SM, Koh C, Kleiner DE, Heller T. Granulomatous liver diseases. Hepatol Commun 2024; 8:e0392. [PMID: 38497932 PMCID: PMC10948139 DOI: 10.1097/hc9.0000000000000392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/18/2023] [Indexed: 03/19/2024] Open
Abstract
A granuloma is a discrete collection of activated macrophages and other inflammatory cells. Hepatic granulomas can be a manifestation of localized liver disease or be a part of a systemic process, usually infectious or autoimmune. A liver biopsy is required for the detection and evaluation of granulomatous liver diseases. The prevalence of granulomas on liver biopsy varies from 1% to 15%. They may be an incidental finding in an asymptomatic individual, or they may represent granulomatous hepatitis with potential to progress to liver failure, or in chronic disease, to cirrhosis. This review focuses on pathogenesis, histological features of granulomatous liver diseases, and most common etiologies, knowledge that is essential for timely diagnosis and intervention.
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Affiliation(s)
- Maria Mironova
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Harish Gopalakrishna
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Gian Rodriguez Franco
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Steven M. Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Christopher Koh
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David E. Kleiner
- Department of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Theo Heller
- Translational Hepatology Section, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
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Viallard JF, Parrens M, Blanco P, Moreau JF, Oksenhendler E, Fieschi C. Influence of Splenomegaly and Splenectomy on the Immune Cell Profile of Patients with Common Variable Immunodeficiency Disease. J Clin Immunol 2024; 44:46. [PMID: 38231432 DOI: 10.1007/s10875-023-01648-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/19/2023] [Indexed: 01/18/2024]
Abstract
PURPOSE About 25% of patients with common variable immunodeficiency disease (CVID) have splenomegaly, necessitating sometimes splenectomy whom consequences on the immunological profile of CVID patients have never been studied. We analyzed 11 CVID patients' comprehensive blood immune cell phenotypes pre- and post-splenectomy. METHODS Flow cytometry analyses of immune cell populations. RESULTS Among 89 CVID cohort patients, 41 with splenomegaly, splenomegaly was strongly associated with granulomatous disease, autoimmune disorders, lymphoid hyperplasia, and/or portal hypertension. CVID patients with splenomegaly have significant peripheral lymphopenia (p = 0.001), and significantly fewer peripheral class-switched memory B cells (smBs) (p = 0.001), CD4+ T lymphocytes (p = 0.001), NK (p = 0.0001) and dendritic cells (p ≤ 0.01), and significantly more circulating CD4+ and CD8+ (p = 0.00001) T cell subset activation (p = 0.00005), than CVID patients without splenomegaly. Examination of splenectomy impact on circulating lymphocyte subset distributions demonstrated the drastically enhanced total circulating lymphocyte count post-splenectomy, predominantly B lymphocytes and CD8+ T cells. However, splenectomy did not change B cell distribution, with smBs remaining persistently low, in contrast to complete inversion of the circulating T cell composition, with reversal of the CD4+/CD8+ ratio suggesting that amplification of the CD8+ T cell compartment is a CVID characteristic in patients with splenomegaly. Our results highlight this CD8+ amplification in CVID-splenomegaly patients that might be explained by a homing effect to the spleen and/or possible chronic virus replication, which in turn could induce T cell expansions. CONCLUSION Splenectomizing CVID patients with splenomegaly restores the absolute circulating lymphocyte count, suggesting that the decreased T cell count in the presence of splenomegaly cannot be used as an exclusive criterion for combined immunodeficiency.
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Affiliation(s)
- Jean-François Viallard
- Department of Internal Medicine and Infectious Diseases, University of Bordeaux, Haut-Lévêque Hospital, 5, Avenue Magellan, 33604, Pessac, France.
| | - Marie Parrens
- Pathology Department, University of Bordeaux, Haut-Lévêque Hospital, 33604, Pessac, France
| | | | | | - Eric Oksenhendler
- Clinical Immunology Department, Saint-Louis Hospital, Paris-Diderot University, 75475, Paris, France
| | - Claire Fieschi
- Clinical Immunology Department, Saint-Louis Hospital, Paris-Diderot University, 75475, Paris, France
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Halliday N, Eden N, Somers H, Burke N, Silva H, Brito CGX, Hall A, Quaglia A, Burns SO, Lowe DM, Thorburn D. Common variable immunodeficiency disorder-related liver disease is common and results in portal hypertension and an increased risk of death. Hepatol Commun 2024; 8:e0322. [PMID: 38099861 PMCID: PMC10727572 DOI: 10.1097/hc9.0000000000000322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/28/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Common variable immunodeficiency disorder (CVID) manifests with recurrent infections and inflammatory complications, including liver disease. We report the clinical features, natural history, and outcomes of patients with CVID-related liver disease (CVID-rLD) from a tertiary immunology and hepatology center. METHODS Two hundred eighteen patients were identified; CVID-rLD was defined by persistently abnormal liver function tests or evidence of chronic liver disease (CLD) or portal hypertension (PHTN) by radiological or endoscopic investigation, after exclusion of other causes. Patients with CVID-rLD were investigated and managed following a joint pathway between immunology and hepatology services. Data, including clinical parameters, investigations, and outcomes, were retrospectively collected. RESULTS A total of 91/218 (42%) patients had evidence of CVID-rLD, and 40/91 (44%) had PHTN. Patients with CVID-rLD were more likely to have other noninfectious complications of CVID (85/91, 93.4% vs. 75/127, 59.1%, p<0.001) including interstitial lung disease, gut disease, and autoimmune cytopenias. Nodular regenerative hyperplasia (NRH) was identified in 63.8% of liver biopsies, and fibrosis in 95.3%. Liver stiffness measurements (LSMs) were frequently elevated (median 9.95 kPa), and elevated LSM was associated with PHTN. All-cause mortality was higher in those with CVID-rLD (24/91, 26.4% vs. 14/127, 11%, p=0.003), which was the only organ complication associated with mortality (HR 2.24, 1.06-4.74, p=0.04). Factors predicting mortality in CVID-rLD included PHTN, increasing fibrosis, and LSM. CONCLUSIONS Liver disease is a common complication of CVID as part of complex, multi-organ involvement and is associated with high rates of PHTN and an increased hazard of mortality.
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Affiliation(s)
- Neil Halliday
- UCL Institute for Liver and Digestive Health, University College London, London, UK
- Sheila Sherlock liver centre, Royal Free London NHS Foundation Trust, London, UK
| | - Nadia Eden
- UCL Institute for Liver and Digestive Health, University College London, London, UK
- Sheila Sherlock liver centre, Royal Free London NHS Foundation Trust, London, UK
| | - Henry Somers
- UCL Institute for Liver and Digestive Health, University College London, London, UK
- Sheila Sherlock liver centre, Royal Free London NHS Foundation Trust, London, UK
| | - Niall Burke
- UCL Institute for Liver and Digestive Health, University College London, London, UK
- Sheila Sherlock liver centre, Royal Free London NHS Foundation Trust, London, UK
| | - Hiroshi Silva
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
| | - Camila GX Brito
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
| | - Andrew Hall
- Sheila Sherlock liver centre, Royal Free London NHS Foundation Trust, London, UK
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
| | - Alberto Quaglia
- UCL Institute for Liver and Digestive Health, University College London, London, UK
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
| | - Siobhan O. Burns
- Institute of Immunity and Transplantation, University College London, UK
- Department of Immunology, Royal Free London NHS Foundation Trust, London, UK
| | - David M. Lowe
- Institute of Immunity and Transplantation, University College London, UK
- Department of Immunology, Royal Free London NHS Foundation Trust, London, UK
| | - Douglas Thorburn
- UCL Institute for Liver and Digestive Health, University College London, London, UK
- Sheila Sherlock liver centre, Royal Free London NHS Foundation Trust, London, UK
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Hanitsch LG, Steiner S, Schumann M, Wittke K, Kedor C, Scheibenbogen C, Fischer A. Portal hypertension in common variable immunodeficiency disorders - a single center analysis on clinical and immunological parameter in 196 patients. Front Immunol 2023; 14:1268207. [PMID: 38187397 PMCID: PMC10769488 DOI: 10.3389/fimmu.2023.1268207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Background Liver manifestations and in particular portal hypertension (PH) contribute significantly to morbidity and mortality of patients with common variable immunodeficiency disorders (CVID). Screening strategies and early detection are limited due to the lack of specific diagnostic tools. Methods We evaluated clinical, immunological, histological, and imaging parameters in CVID patients with clinical manifestation of portal hypertension (CVID+PH). Results Portal hypertension was present in 5.6% of CVID patients and was associated with high clinical burden and increased mortality (18%). Longitudinal data on clinical and immunological parameters in patients before and during clinically manifest portal hypertension revealed a growing splenomegaly and increasing gamma-glutamyl transferase (GGT) and soluble interleukin 2 receptor (SIL-2R) levels with decreasing platelets over time. While ultrasound of the liver failed to detect signs of portal hypertension in most affected patients, transient elastography was elevated in all patients. All CVID+PH patients had reduced naïve CD45RA+CD4+ T-cells (mean of 6,2%). The frequency of severe B-lymphocytopenia (Euroclass B-) was higher in CVID+PH patients. The main histological findings included lymphocytic infiltration, nodular regenerative hyperplasia-like changes (NRH-LC), and porto(-septal) fibrosis. Conclusion CVID patients with lower naïve CD45RA+CD4+ T-cells or severely reduced B-cells might be at higher risk for portal hypertension. The combination of biochemical (increasing sIL-2R, GGT, and decreasing platelets) and imaging parameters (increasing splenomegaly) should raise suspicion of the beginning of portal hypertension.
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Affiliation(s)
- Leif G. Hanitsch
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
| | - Sophie Steiner
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Michael Schumann
- Department of Gastroenterology, Infectiology and Rheumatology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Kirsten Wittke
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Claudia Kedor
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Carmen Scheibenbogen
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
| | - Andreas Fischer
- Department of Internal Medicine and Gastroenterology, Caritas-Klinik Maria Heimsuchung Berlin-Pankow, Berlin, Germany
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
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10
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Hultberg J, Blixt E, Göransson R, Adolfsson J, Govender M, Larsson M, Nilsdotter-Augustinsson Å, Ernerudh J, Nyström S. In-depth immune profiling reveals advanced B- and T-cell differentiation to be associated with Th1-driven immune dysregulation in common variable immunodeficiency. Clin Immunol 2023; 257:109816. [PMID: 37918468 DOI: 10.1016/j.clim.2023.109816] [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: 06/07/2023] [Revised: 10/25/2023] [Accepted: 10/27/2023] [Indexed: 11/04/2023]
Abstract
Common variable immunodeficiency (CVID) is an inborn error of immunity characterized by low levels of antibodies. In addition to infections, many patients also suffer from T-helper 1-driven immune dysregulation, which is associated with increased mortality. The aim of this study was to perform in-depth characterization of the T and the B cell compartments in a well-defined cohort of patients affected by CVID and correlate the findings to the level of clinical immune dysregulation. We used mass cytometry, targeted proteomics, flow cytometry and functional assays to delineate the immunological phenotype of 15 CVID-affected patients with different levels of immune dysregulation. Unbiased clustering of T cell mass cytometry data correlated with CVID-related immune dysregulation and plasma protein profiles. Expanded CXCR3+ T-bet-expressing B cells correlated with effector memory CD4+ T cell clusters, and increased plasma levels of CXCR3-ligands. Our findings indicate an interplay between B cells and T cells in CVID-related immune dysregulation and provide a better understanding of the underlying pathological mechanisms.
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Affiliation(s)
- Jonas Hultberg
- Division of Molecular Medicine and Virology, Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Emelie Blixt
- Department of Clinical Immunology and Transfusion Medicine, and Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Robin Göransson
- Department of Clinical Immunology and Transfusion Medicine, and Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Jörgen Adolfsson
- Division of Molecular Medicine and Virology, Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Melissa Govender
- Division of Molecular Medicine and Virology, Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Marie Larsson
- Division of Molecular Medicine and Virology, Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Åsa Nilsdotter-Augustinsson
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Jan Ernerudh
- Department of Clinical Immunology and Transfusion Medicine, and Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Sofia Nyström
- Department of Clinical Immunology and Transfusion Medicine, and Department of Biomedical and Clinical Sciences, Linköping University, Sweden.
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11
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Baumert LS, Shih A, Chung RT. Management of liver disease and portal hypertension in common variable immunodeficiency (CVID). JHEP Rep 2023; 5:100882. [PMID: 37869072 PMCID: PMC10585302 DOI: 10.1016/j.jhepr.2023.100882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/30/2023] [Accepted: 07/22/2023] [Indexed: 10/24/2023] Open
Abstract
Patients with common variable immunodeficiency (CVID) frequently develop liver disease and associated complications, which represent an increasingly prevalent unmet medical need. The main hepatic manifestation of CVID is nodular regenerative hyperplasia (NRH), resulting in non-cirrhotic portal hypertension (NCPH). Liver disease is often underdiagnosed, leading to poor outcomes and decreased survival. The increasing numbers of patients with CVID who are diagnosed late with progressive liver disease underscores the importance of appropriate clinical management and treatment of liver complications. At the same time, specific guidelines for the clinical management of CVID-related liver disease are still lacking. Here, we review the epidemiology of CVID-related liver disease, reveal new insights into NRH and NCPH biology and highlight recently uncovered opportunities for NCPH diagnostics in CVID. Finally, we focus on current management of liver disease, portal hypertension and its complications - the key challenge in patients with CVID. Specifically, we review recent data regarding the role of transjugular intrahepatic portosystemic shunt and liver transplantation in clinical management. The role for anticoagulants and immunosuppressants targeting the pathogenesis of NRH will also be discussed. We propose an updated algorithm for the diagnostic work-up and treatment of NCPH in CVID. Finally, we consider future needs and therapeutic opportunities for CVID-related liver disease.
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Affiliation(s)
- Lukas S. Baumert
- Liver Center, Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Faculty of Medicine, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Angela Shih
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond T. Chung
- Liver Center, Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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12
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Silva H, Brito CGXD, Hall A, Eden N, Somers H, Burke N, Burns SO, Lowe D, Thorburn D, Halliday N, Quaglia A. Common variable immunodeficiency disorder (CVID)-related liver disease: assessment of the main histological aspects using novel semiquantitative scoring systems, image analysis and correlation with clinical parameters of liver stiffness and portal hypertension. J Clin Pathol 2023:jcp-2023-208977. [PMID: 37553247 DOI: 10.1136/jcp-2023-208977] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/14/2023] [Indexed: 08/10/2023]
Abstract
AIMS We aimed to investigate the relationship between T-cell-mediated sinusoidal injury, nodular regenerative hyperplasia like changes (NRH-LC) and fibrosis, clinical measures of fibrosis and portal hypertension, and progression rate in common variable immunodeficiency disorder (CVID)-related liver disease. METHODS This is a retrospective single-centre study. Liver biopsies from CVID patients with liver disease were reviewed to assess for NRH-LC, fibrosis and elastosis, including collagen and elastin proportionate areas. CD3 positive T-cells infiltration and sinusoidal endothelial changes by CD34 expression were quantified by image analysis and a semiquantitative method, respectively. These findings were correlated with liver stiffness measurements (LSM) and hepatic venous pressure gradient (HVPG). RESULTS NRH-LC and pericellular elastosis were present in most biopsies (32/40 and 38/40, respectively). All biopsies showed fibrosis, which was limited to pericellular in 21/40 (52.5%) and included bridging fibrous septa in 19/40 (47.5%). 28/40 liver biopsies showed enhanced sinusoidal expression of CD34. There were more CD3 positive cells in biopsies with NRH-LC compared with those without. There was no significant correlation between LSM, HVPG and fibrosis/elastosis scores. Five of seven patients with at least two biopsies showed progression in fibrosis stage. CONCLUSIONS NRH-LC and fibrosis in CVID patients often coexist along with the presence of sinusoidal endothelial changes and sinusoidal lymphocytic infiltration. Fibrosis progresses over time, and significant fibrosis can be observed in young patients (<30 years old), potentially reflecting a more aggressive form of CVID-related liver disease. Further studies are necessary to investigate the relationship between histological findings, clinical measures of fibrosis and portal hypertension and outcome.
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Affiliation(s)
- Hiroshi Silva
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
| | | | - Andrew Hall
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
| | - Nadia Eden
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Henry Somers
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Niall Burke
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Siobhan O Burns
- Institute of Immunity and Transplantation, University College London, London, UK
- Department of Immunology, Royal Free London NHS Foundation Trust, London, UK
| | - David Lowe
- Institute of Immunity and Transplantation, University College London, London, UK
- Department of Immunology, Royal Free London NHS Foundation Trust, London, UK
| | - Douglas Thorburn
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Neil Halliday
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Alberto Quaglia
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
- Institute for Liver and Digestive Health, University College London, London, UK
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13
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Di Giorgio A, Matarazzo L, Sonzogni A, Nicastro E, Pietrobattista A, Cananzi M, Gaio P, Sciveres M, Di Leo G, Iorio R, Marseglia A, Carioli G, Maggiore G, Guido M, D'Antiga L. Paediatric porto-sinusoidal vascular disease: Two different clinical phenotypes with subtle histological differences. Liver Int 2023. [PMID: 37157951 DOI: 10.1111/liv.15603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/13/2023] [Accepted: 04/23/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND AND AIMS In paediatrics, porto-sinusoidal vascular disease (PSVD) is relatively unknown and probably underdiagnosed. We aimed to describe clinical phenotypes, histology and outcome of children diagnosed with PSVD. METHODS Retrospective multicentre study of children diagnosed with PSVD. Diagnosis of PSVD was based on histopathology reports; liver specimens were re-evaluated by two expert liver pathologists. RESULTS Sixty two children diagnosed with PSVD (M/F = 36/26, median age 6.6 years, range 3.3-10.6), from 7 centres, were included. Thirty-six presented with non-cirrhotic portal hypertension, PH, (PH-PSVD Group = 58%) while 26 had a liver biopsy because of chronic elevation of transaminases without PH (noPH-PSVD Group = 42%). On histology review, the two groups differed for the prevalence of obliterative portal venopathy (more prevalent in PH-PSVD, p = 0.005), and hypervascularised portal tracts (more common in noPH-PSVD, p = 0.039), the other histological changes were equally distributed. At multivariate analysis, platelet count ≤185 000/mm3 was the only independent determinant of PH (p < 0.001). After a median follow-up of 7 years (range 3.0-11.2), in PH-PSVD group 3/36 (8%) required TIPS placement, 5/36 (14%) developed pulmonary vascular complications of PH, and 7/36 (19%) required liver transplantation. In noPH-PSVD none progressed to PH nor had complications. CONCLUSIONS Paediatric patients with PSVD present with two different clinical phenotypes, one characterised by PH and one by chronic elevation of transaminases without PH. PSVD should be included among the conditions causing isolated hypertransaminasaemia. On histology, the differences between the two groups are subtle. Medium-term outcome is favourable in patients without PH; progression of the disease is observed in those with PH.
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Affiliation(s)
- Angelo Di Giorgio
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Lorenza Matarazzo
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | | | - Emanuele Nicastro
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Andrea Pietrobattista
- Hepatology, Gastroenterology, Digestive Endoscopy, Nutrition, and Liver Transplantation Unit, IRCCS Bambino Gesù, Pediatric Hospital, Rome, Italy
| | - Mara Cananzi
- Unit of Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, University Hospital of Padova, Padova, Italy
| | - Paola Gaio
- Unit of Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, University Hospital of Padova, Padova, Italy
| | - Marco Sciveres
- Paediatric Department and Transplantation, ISMETT, Palermo, Italy
| | | | - Raffaele Iorio
- Department of Translational Medical Science, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Antonio Marseglia
- Fondazione IRCCS Casa Sollievo della Sofferenza, Division of Pediatrics, San Giovanni Rotondo, Italy
| | - Greta Carioli
- FROM Research Foundation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Maggiore
- Hepatology, Gastroenterology, Digestive Endoscopy, Nutrition, and Liver Transplantation Unit, IRCCS Bambino Gesù, Pediatric Hospital, Rome, Italy
| | - Maria Guido
- Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Lorenzo D'Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
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14
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Fevang B. Treatment of inflammatory complications in common variable immunodeficiency (CVID): current concepts and future perspectives. Expert Rev Clin Immunol 2023; 19:627-638. [PMID: 36996348 DOI: 10.1080/1744666x.2023.2198208] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
INTRODUCTION Patients with Common variable immunodeficiency (CVID) have a high frequency of inflammatory complications like autoimmune cytopenias, interstitial lung disease and enteropathy. These patients have poor prognosis and effective, timely and safe treatment of inflammatory complications in CVID are essential, but guidelines and consensus on therapy are often lacking. AREAS COVERED This review will focus on current medical treatment of inflammatory complications in CVID and point out some future perspectives based on literature indexed in PubMed. There are a number of good observational studies and case reports on treatment of specific complications but randomized controlled trials are scarce. EXPERT OPINION In clinical practice, the most urgent issues that need to be addressed are the preferred treatment of GLILD, enteropathy and liver disease. Treating the underlying immune dysregulation and immune exhaustion in CVID is an alternative approach that potentially could alleviate these and other organ-specific inflammatory complications. Therapies of potential interest and wider use in CVID include mTOR-inhibitors like sirolimus, JAK-inhibitors like tofacitinib, the monoclonal IL-12/23 antibody ustekinumab, the anti-BAFF antibody belimumab and abatacept. For all inflammatory complications, there is a need for prospective therapeutic trials, preferably randomized controlled trials, and multi-center collaborations with larger cohorts of patients will be essential.
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Affiliation(s)
- Børre Fevang
- Centre for Rare Disorders, Oslo University Hospital, Oslo, Norway
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Oslo, Norway
- Research Institute for Internal Medicine, Oslo University Hospital, Oslo, Norway
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15
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Sharma D, Ben Yakov G, Kapuria D, Viana Rodriguez G, Gewirtz M, Haddad J, Kleiner DE, Koh C, Bergerson JRE, Freeman AF, Heller T. Tip of the iceberg: A comprehensive review of liver disease in Inborn errors of immunity. Hepatology 2022; 76:1845-1861. [PMID: 35466407 DOI: 10.1002/hep.32539] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 03/30/2022] [Accepted: 04/17/2022] [Indexed: 12/08/2022]
Abstract
Inborn errors of immunity (IEIs) consist of numerous rare, inherited defects of the immune system that affect about 500,000 people in the United States. As advancements in diagnosis through genetic testing and treatment with targeted immunotherapy and bone marrow transplant emerge, increasing numbers of patients survive into adulthood posing fresh clinical challenges. A large spectrum of hepatobiliary diseases now present in those with immunodeficiency diseases, leading to morbidity and mortality in this population. Awareness of these hepatobiliary diseases has lagged the improved management of the underlying disorders, leading to missed opportunities to improve clinical outcomes. This review article provides a detailed description of specific liver diseases occurring in various inborn errors of immunity. A generalized approach to diagnosis and management of hepatic complications is provided, and collaboration with hepatologists, immunologists, and pathologists is emphasized as a requirement for optimizing management and outcomes.
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Affiliation(s)
- Disha Sharma
- Department of Internal MedicineMedStar Washington Hospital Center & Georgetown UniversityWashingtonDCUSA.,Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - Gil Ben Yakov
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA.,26744Center for Liver DiseaseSheba Medical CenterTel HaShomerIsrael
| | - Devika Kapuria
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA.,Department of GastroenterologyUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Gracia Viana Rodriguez
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - Meital Gewirtz
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - James Haddad
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - David E Kleiner
- 3421Laboratory of PathologyNational Cancer InstituteBethesdaMarylandUSA
| | - Christopher Koh
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - Jenna R E Bergerson
- Laboratory of Clinical Immunology and MicrobiologyNIAID, NIHBethesdaMarylandUSA
| | - Alexandra F Freeman
- Laboratory of Clinical Immunology and MicrobiologyNIAID, NIHBethesdaMarylandUSA
| | - Theo Heller
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
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16
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Lima FMS, Toledo-Barros M, Alves VAF, Duarte MIS, Takakura C, Bernardes-Silva CF, Marinho AKBB, Grecco O, Kalil J, Kokron CM. Liver disease accompanied by enteropathy in common variable immunodeficiency: Common pathophysiological mechanisms. Front Immunol 2022; 13:933463. [PMID: 36341360 PMCID: PMC9632424 DOI: 10.3389/fimmu.2022.933463] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 09/29/2022] [Indexed: 11/16/2022] Open
Abstract
Common variable immunodeficiency (CVID) is one of the inborn errors of immunity that have the greatest clinical impact. Rates of morbidity and mortality are higher in patients with CVID who develop liver disease than in those who do not. The main liver disorder in CVID is nodular regenerative hyperplasia (NRH), the cause of which remains unclear and for which there is as yet no treatment. The etiology of liver disease in CVID is determined by analyzing the liver injury and the associated conditions. The objective of this study was to compare CVID patients with and without liver–spleen axis abnormalities in terms of clinical characteristics, as well as to analyze liver and duodenal biopsies from those with portal hypertension (PH), to elucidate the pathophysiology of liver injury. Patients were divided into three groups: Those with liver disease/PH, those with isolated splenomegaly, and those without liver–spleen axis abnormalities. Clinical and biochemical data were collected. Among 141 CVID patients, 46 (32.6%) had liver disease/PH; 27 (19.1%) had isolated splenomegaly; and 68 (48.2%) had no liver–spleen axis abnormalities. Among the liver disease/PH group, patients, even those with mild or no biochemical changes, had clinical manifestations of PH, mainly splenomegaly, thrombocytopenia, and esophageal varices. Duodenal celiac pattern was found to correlate with PH (p < 0.001). We identified NRH in the livers of all patients with PH (n = 11). Lymphocytic infiltration into the duodenal mucosa also correlated with PH. Electron microscopy of liver biopsy specimens showed varying degrees of lymphocytic infiltration and hepatocyte degeneration, which is a probable mechanism of lymphocyte-mediated cytotoxicity against hepatocytes and enterocytes. In comparison with the CVID patients without PH, those with PH were more likely to have lymphadenopathy (p < 0.001), elevated β2-microglobulin (p < 0.001), low B-lymphocyte counts (p < 0.05), and low natural killer-lymphocyte counts (p < 0.05). In CVID patients, liver disease/PH is common and regular imaging follow-up is necessary. These patients have a distinct immunological phenotype that may predispose to liver and duodenal injury from lymphocyte-mediated cytotoxicity. Further studies could elucidate the cause of this immune-mediated mechanism and its treatment options.
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Affiliation(s)
- Fabiana Mascarenhas Souza Lima
- Division of Clinical Immunology and Allergy, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- *Correspondence: Fabiana Mascarenhas Souza Lima,
| | - Myrthes Toledo-Barros
- Division of Clinical Immunology and Allergy, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Maria Irma Seixas Duarte
- Laboratory of the Discipline of Pathology of Transmissible Diseases, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Cleusa Takakura
- Laboratory of the Discipline of Pathology of Transmissible Diseases, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Carlos Felipe Bernardes-Silva
- Department of Gastroenterology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Octavio Grecco
- Division of Clinical Immunology and Allergy, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Jorge Kalil
- Division of Clinical Immunology and Allergy, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- iii-Institute for Investigation in Immunology, Instituto Nacional de Ciência e Tecnologia (INCT), Sao Paulo, Brazil
| | - Cristina Maria Kokron
- Division of Clinical Immunology and Allergy, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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17
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De Gottardi A, Sempoux C, Berzigotti A. Porto-sinusoidal vascular disorder. J Hepatol 2022; 77:1124-1135. [PMID: 35690264 DOI: 10.1016/j.jhep.2022.05.033] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/15/2022] [Accepted: 05/23/2022] [Indexed: 12/04/2022]
Abstract
It is well established that portal hypertension can occur in the absence of cirrhosis, as reported in patients with immune disorders, infections and thrombophilia. However, similar histological abnormalities primarily affecting the hepatic sinusoidal and (peri)portal vasculature have also been observed in patients without portal hypertension. Thus, the term porto-sinusoidal vascular disorder (PSVD) has recently been introduced to describe a group of vascular diseases of the liver featuring lesions encompassing the portal venules and sinusoids, irrespective of the presence/absence of portal hypertension. Liver biopsy is fundamental for PSVD diagnosis. Specific histology findings include nodular regenerative hyperplasia, obliterative portal venopathy/portal vein stenosis and incomplete septal fibrosis/cirrhosis. Since other conditions including alcohol-related and non-alcoholic fatty liver disease, or viral hepatitis, or the presence of portal vein thrombosis may occur in patients with PSVD, their relative contribution to liver damage should be carefully assessed. In addition to histology and clinical diagnostic criteria, imaging and non-invasive tests such as liver and spleen stiffness measurements could aid in the diagnostic workup. The introduction of PSVD as a novel clinical entity will facilitate collaborative studies and investigations into the underlying molecular pathomechanisms encompassed by this term.
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Affiliation(s)
- Andrea De Gottardi
- Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.
| | - Christine Sempoux
- Service of Clinical Pathology, Institute of Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Annalisa Berzigotti
- Department for Visceral Medicine and Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
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18
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Globig AM, Strohmeier V, Surabattula R, Leeming DJ, Karsdal MA, Heeg M, Kindle G, Goldacker S, von Spee-Mayer C, Proietti M, Bausch B, Bettinger D, Schultheiß M, Thimme R, Schuppan D, Warnatz K. Evaluation of Laboratory and Sonographic Parameters for Detection of Portal Hypertension in Patients with Common Variable Immunodeficiency. J Clin Immunol 2022; 42:1626-1637. [PMID: 35821451 DOI: 10.1007/s10875-022-01319-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/24/2022] [Indexed: 11/26/2022]
Abstract
Timely detection of portal hypertension as a manifestation in a subgroup of patients with common variable immunodeficiency (CVID) represents a challenge since it is usually not associated with liver cirrhosis. To identify relevant markers for portal hypertension, we evaluated clinical history, laboratory parameters, and abdominal ultrasound including liver elastography and biomarkers of extracellular matrix formation. Twenty seven (6%) of 479 CVID patients presented with clinically significant portal hypertension as defined by either the presence of esophageal varices or ascites. This manifestation occurred late during the course of the disease (11.8 years after first diagnosis of CVID) and was typically part of a multiorgan disease and associated with a high mortality (11/27 patients died during follow up). The strongest association with portal hypertension was found for splenomegaly with a longitudinal diameter of > 16 cm. Similarly, most patients presented with a liver stiffness measurement (LSM) of above 6.5 kPa, and a LSM above 20 kPa was always indicative of manifest portal hypertension. Additionally, many laboratory parameters including Pro-C4 were significantly altered in patients with portal hypertension without clearly increasing the discriminatory power to detect non-cirrhotic portal hypertension in CVID. Our data suggest that a spleen size above 16 cm and an elevated liver stiffness above 6.5 kPa should prompt further evaluation of portal hypertension and its sequelae, but earlier and better liquid biomarkers of this serious secondary complication in CVID are needed.
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Affiliation(s)
- Anna-Maria Globig
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology, and Infectious Diseases, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Valentina Strohmeier
- Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, University of Freiburg, University of Freiburg, Breisacher Str. 115, 79106, Freiburg, Germany
- Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, University of Freiburg, University of Freiburg, Freiburg, Germany
- Faculty of Biology, University of Freiburg, Schaenzlestrasse 1, Freiburg, Germany
| | - Rambabu Surabattula
- Institute of Translational Immunology and Research Center for Immune Therapy, Mainz University Medical Center, 55131, Mainz, Germany
| | | | | | - Maximilian Heeg
- Institute for Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gerhard Kindle
- Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, University of Freiburg, University of Freiburg, Freiburg, Germany
- Institute for Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sigune Goldacker
- Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, University of Freiburg, University of Freiburg, Breisacher Str. 115, 79106, Freiburg, Germany
- Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Caroline von Spee-Mayer
- Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, University of Freiburg, University of Freiburg, Breisacher Str. 115, 79106, Freiburg, Germany
- Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, University of Freiburg, University of Freiburg, Freiburg, Germany
- Institute for Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michele Proietti
- Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, University of Freiburg, University of Freiburg, Freiburg, Germany
- Institute for Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
- Cluster of Excellence RESIST (EXC 2155), Hannover Medical School, Hannover, Germany
| | - Birke Bausch
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology, and Infectious Diseases, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology, and Infectious Diseases, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Schultheiß
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology, and Infectious Diseases, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology, and Infectious Diseases, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Detlef Schuppan
- Institute of Translational Immunology and Research Center for Immune Therapy, Mainz University Medical Center, 55131, Mainz, Germany
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Klaus Warnatz
- Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, University of Freiburg, University of Freiburg, Breisacher Str. 115, 79106, Freiburg, Germany.
- Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, University of Freiburg, University of Freiburg, Freiburg, Germany.
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19
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Sompornrattanaphan M, Tongdee R, Wongsa C, Jitmuang A, Thongngarm T. Fatal liver mass rupture in a common-variable-immunodeficiency patient with probable nodular regenerating hyperplasia. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:2. [PMID: 34996523 PMCID: PMC8742317 DOI: 10.1186/s13223-021-00643-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 12/13/2021] [Indexed: 11/26/2022]
Abstract
Background Nodular regenerating hyperplasia (NRH) is the most common liver involvement in common variable immunodeficiency (CVID). Most patients are asymptomatic with gradually increasing alkaline phosphatase (ALP) and mildly elevated transaminase enzymes over the years. We report the first case of fatal liver mass rupture in a CVID patient with probable NRH. Case presentation A 24-year-old man was diagnosed with CVID at the age of 1.25 years. Genetic testing revealed a transmembrane activator and calcium-modulator and cyclophilin-ligand interactor (TACI) mutation. He had been receiving intravenous immunoglobulin (IVIg) replacement therapy ever since then. The trough level of serum IgG ranged between 750–1200 mg/dL. However, he still had occasional episodes of lower respiratory tract infection until bronchiectasis developed. At 22 years old, computed tomography (CT) chest and abdomen as an investigation for lung infection revealed incidental findings of numerous nodular arterial-enhancing lesions in the liver and mild splenomegaly suggestive of NRH with portal hypertension. Seven months later, he developed sudden hypotension and tense bloody ascites. Emergency CT angiography of the abdomen showed NRH with intrahepatic hemorrhage and hemoperitoneum. Despite successful gel foam embolization, the patient died from prolonged shock and multiple organ failure. Conclusions Although CVID patients with NRH are generally asymptomatic, late complications including portal hypertension, hepatic failure, and hepatic rupture could occur. Therefore, an evaluation of liver function should be included in the regular follow-up of CVID patients.
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Affiliation(s)
- Mongkhon Sompornrattanaphan
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Ranista Tongdee
- Department of Diagnostic Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chamard Wongsa
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Anupop Jitmuang
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Torpong Thongngarm
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand.
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20
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Abstract
INTRODUCTION There is a wide spectrum of noninfectious gastrointestinal pathology, causing considerable morbidity and mortality in CVID, where both etiology and effective therapy are under debate. AREAS COVERED This review will focus on the noninfectious inflammation in the GI tract in CVID patients, covering the both the upper and lower GI tract inflammation, including the liver. The controversy of the CVID enteropathy definition and that of gluten-free diet for celiac-like disease in CVID will be discussed. Furthermore, the review will cover the link between GI inflammation and GI cancer. Finally, the role of gut microbiota, IgA, and genetics and its relationship with CVID enteropathy is scrutinized. The authors reviewed literature from PubMed. EXPERT OPINION The heterogeneity and the unknown mechanism behind CVID enteropathy, and thereby the lack of effective treatment, is one of the key challenges in the field of CVID. Celiac-like disease in CVID is due to immune dysregulation, and a gluten-free diet is therefore not indicated. Gut microbial dysbiosis and mucosal IgA can initiate systemic and local inflammation and is involved in the immune dysregulation in CVID. Considering the heterogeneity of CVID enteropathy, personalized medicine is probably the future for these patients.
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Affiliation(s)
- I M Andersen
- Section of Clinical Immunology and Infectious Diseases, Department of Rheumatology, Dermatology and Infectious Diseases, Oslo University Hospital, Rikshospitalet, Norway
| | - S F Jørgensen
- Section of Clinical Immunology and Infectious Diseases, Department of Rheumatology, Dermatology and Infectious Diseases, Oslo University Hospital, Rikshospitalet, Norway.,Research Institute of Internal Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Norway
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21
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DiGiacomo DV, Shay JE, Crotty R, Yang N, Bloom P, Corey K, Barmettler S, Farmer JR. Liver Stiffness by Transient Elastography Correlates With Degree of Portal Hypertension in Common Variable Immunodeficiency Patients With Nodular Regenerative Hyperplasia. Front Immunol 2022; 13:864550. [PMID: 35603209 PMCID: PMC9121126 DOI: 10.3389/fimmu.2022.864550] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/04/2022] [Indexed: 01/11/2023] Open
Abstract
Nodular regenerative hyperplasia (NRH) is associated with high morbidity and mortality in patients with common variable immunodeficiency (CVID). While liver biopsy is the gold standard for NRH diagnosis, a non-invasive technique could facilitate early disease recognition, monitoring, and/or immune intervention. We performed a cross-sectional analysis of ultrasound-based transient elastography (TE) in patients with CVID to evaluate liver stiffness and compared this between patients with (N = 12) and without (N = 6) biopsy-proven NRH. Additionally, these data were compared to a cohort followed at our institution for non-alcoholic fatty liver disease (NAFLD) (N = 527), a disease for which TE has routine diagnostic use. Clinical and pathologic features of NRH were evaluated as correlates of liver stiffness, and receiver operating characteristic curves were used to define a liver stiffness cutoff with diagnostic utility for NRH among CVID patients. CVID patients with NRH had a more severe disease presentation compared to those without. This included increased autoinflammatory disease comorbidities, combined B-cell and T-cell dysfunction, and abnormal liver biochemistries (specifically an increased mean alkaline phosphatase level [proximal to TE, 250 vs. 100 U/L; p = 0.03; peak, 314 vs. 114 U/L; p = 0.02). Results of TE demonstrated a significantly elevated liver stiffness in CVID patients with NRH (mean 13.2 ± 6.2 kPa) as compared to both CVID patients without NRH (mean 4.6 ± 0.9 kPa) and non-CVID patients with NAFLD (mean 6.9 ± 5.5 kPa) (p < 0.01). No single or composite histopathologic feature of NRH correlated with liver stiffness including nodule size, nodule density, sinusoidal dilation, fibrosis, and/or lymphocytosis. In contrast, liver stiffness by TE was significantly correlated with clinical parameters of portal hypertension, including an elevated hepatic venous pressure gradient, an increased splenic longitudinal diameter, presence of varices, and presence of peripheral edema. A liver stiffness of greater than or equal to 6.2 kPa was a clinically significant cutoff for NRH in CVID patients. We propose that TE has diagnostic utility in CVID, particularly in the presence of immunophenotypic features such as combined B-cell and T-cell dysfunction, autoinflammatory comorbidities, and/or abnormal liver tests. Elevated liver stiffness by TE should raise suspicion for NRH in patients with CVID and prompt expedited evaluation by hepatology.
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Affiliation(s)
- Daniel V DiGiacomo
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, United States
| | - Jessica E Shay
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - Rory Crotty
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Nancy Yang
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, United States
| | - Patricia Bloom
- Department of Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, MI, United States
| | - Kathleen Corey
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - Sara Barmettler
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, United States
| | - Jocelyn R Farmer
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, United States
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22
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Nunes-Santos CJ, Koh C, Rai A, Sacco K, Marciano BE, Kleiner DE, Marko J, Bergerson JRE, Stack M, Rivera MM, Constantine G, Strober W, Uzel G, Fuss IJ, Notarangelo LD, Holland SM, Rosenzweig SD, Heller T. Nodular regenerative hyperplasia in X-linked agammaglobulinemia: An underestimated and severe complication. J Allergy Clin Immunol 2022; 149:400-409.e3. [PMID: 34087243 PMCID: PMC8633079 DOI: 10.1016/j.jaci.2021.05.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/30/2021] [Accepted: 05/14/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Late-onset complications in X-linked agammaglobulinemia (XLA) are increasingly recognized. Nodular regenerative hyperplasia (NRH) has been reported in primary immunodeficiency but data in XLA are limited. OBJECTIVES This study sought to describe NRH prevalence, associated features, and impact in patients with XLA. METHODS Medical records of all patients with XLA referred to the National Institutes of Health between October 1994 and June 2019 were reviewed. Liver biopsies were performed when clinically indicated. Patients were stratified into NRH+ or NRH- groups, according to their NRH biopsy status. Fisher exact test and Mann-Whitney test were used for statistical comparisons. RESULTS Records of 21 patients with XLA were reviewed, with a cumulative follow-up of 129 patient-years. Eight patients underwent ≥1 liver biopsy of whom 6 (29% of the National Institutes of Health XLA cohort) were NRH+. The median age at NRH diagnosis was 20 years (range, 17-31). Among patients who had liver biopsies, alkaline phosphatase levels were only increased in patients who were NRH+ (P = .04). Persistently low platelet count (<100,000 per μL for >6 months), mildly to highly elevated hepatic venous pressure gradient and either hepatomegaly and/or splenomegaly were present in all patients who were NRH+. In opposition, persistently low platelet counts were not seen in patients who were NRH-, and hepatosplenomegaly was observed in only 1 patient who was NRH-. Hepatic venous pressure gradient was normal in the only patient tested who was NRH-. All-cause mortality was higher among patients who were NRH+ (5 of 6, 83%) than in the rest of the cohort (1 of 15, 7% among patients who were NRH- and who were classified as unknown; P = .002). CONCLUSIONS NRH is an underreported, frequent, and severe complication in XLA, which is associated with increased morbidity and mortality.
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Affiliation(s)
- CJ Nunes-Santos
- Immunology Service, Department of Laboratory Medicine, National Institutes of Health (NIH) Clinical Center, Bethesda, MD, USA
| | - C Koh
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, NIH, Bethesda, MD, USA
| | - A Rai
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, NIH, Bethesda, MD, USA
| | - K Sacco
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - BE Marciano
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - DE Kleiner
- Laboratory of Pathology, National Cancer Institute, NIH, Bethesda, MD, USA
| | - J Marko
- Department of Radiology and Imaging Sciences, Clinical Center, NIH, Bethesda, MD
| | - JRE Bergerson
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - M Stack
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - MM Rivera
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, NIH, Bethesda, MD, USA
| | - G Constantine
- National Institute of Allergy and Infectious Diseases Allergy and Immunology Fellowship Program, NIH, Bethesda, Maryland
| | - W Strober
- Mucosal Immunity Section, Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - G Uzel
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - IJ Fuss
- Mucosal Immunity Section, Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - LD Notarangelo
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - SM Holland
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - SD Rosenzweig
- Immunology Service, Department of Laboratory Medicine, National Institutes of Health (NIH) Clinical Center, Bethesda, MD, USA, corresponding authors Sergio D. Rosenzweig, MD, PhD, ; Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, Building 10, Room 2C306, 10 Center Drive, Bethesda, MD, 20892 and Theo Heller, MD, ; Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, NIH, 10 Center Drive, Bethesda, MD 20892
| | - T Heller
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, NIH, Bethesda, MD, USA, corresponding authors Sergio D. Rosenzweig, MD, PhD, ; Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, Building 10, Room 2C306, 10 Center Drive, Bethesda, MD, 20892 and Theo Heller, MD, ; Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, NIH, 10 Center Drive, Bethesda, MD 20892
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23
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Kogami T, Uojima H, Ebato T, Bando Y, Hoshino A, Saegusa M, Ohbu M, Iwasaki S, Wada N, Kubota K, Tanaka Y, Hidaka H, Nakazawa T, Shibuya A, Koizumi W. Cartilage-hair Hypoplasia Complicated with Liver Cirrhosis Due to Chronic Intrahepatic Cholestasis. Intern Med 2021; 60:3427-3433. [PMID: 33967143 PMCID: PMC8627820 DOI: 10.2169/internalmedicine.7483-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
We herein report a rare case of cartilage-hair hypoplasia (CHH) complicated with liver cirrhosis. A 20-year-old Japanese man with CHH was found incidentally to have liver cirrhosis and an esophageal varix. This patient had been treated for infections due to immunodeficiency since early childhood. He ultimately died of liver failure at 31 years of age. An autopsy revealed an abnormality of the interlobular bile ducts and intrahepatic cholestasis. Liver cirrhosis was thought to have been caused by chronic intrahepatic cholestasis due to biliary duct hypoplasia and changes in the intestinal microbiome. Therefore, CHH may cause biliary cirrhosis due to multiple effects.
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Affiliation(s)
- Taro Kogami
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Japan
| | - Haruki Uojima
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Japan
| | - Takasuke Ebato
- Department of Pediatrics, Kitasato University School of Medicine, Japan
| | - Yuki Bando
- Department of Pediatrics, Kitasato University School of Medicine, Japan
| | - Akiyoshi Hoshino
- Department of Pathology, Kitasato University School of Medicine, Japan
| | - Makoto Saegusa
- Department of Pathology, Kitasato University School of Medicine, Japan
| | - Makoto Ohbu
- Department of Pathology, Kitasato Institute Hospital, Japan
| | - Shuichiro Iwasaki
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Japan
| | - Naohisa Wada
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Japan
| | - Kousuke Kubota
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Japan
| | - Yoshiaki Tanaka
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Japan
| | - Hisashi Hidaka
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Japan
| | - Takahide Nakazawa
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Japan
| | - Akitaka Shibuya
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Japan
| | - Wasaburo Koizumi
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Japan
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24
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Bai L, Rohrer C, Liu Y. Liver Histology in Short Telomere Syndrome: A Case Report and Review of the Literature. Int J Surg Pathol 2021; 30:350-355. [PMID: 34714693 DOI: 10.1177/10668969211054102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Short telomere syndrome (STS) encompasses a broad family of genetically inherited conditions caused by various mutations in telomerase and other telomere maintenance genes, resulting in premature telomere shortening. STS involves a variety of clinical manifestations, including dyskeratosis congenita, premature achromotrichia, bone marrow failure, immunodeficiency, pulmonary fibrosis and liver disease. Liver histopathologic features in STS patients have not been well characterized. We report a 46-year-old male patient who presented for dyspnea. The patient had a complicated medical history significant for immune thrombocytopenic purpura and splenectomy, recurrent respiratory tract infections, pneumonia, primary immunodeficiency, and severe hepatopulmonary syndrome. He and his brother both developed gray hair by their late 20s. He had a long history of intermittently elevated liver enzymes starting at age 33. These clinical manifestations prompted an evaluation for a possible telomere biology disorder, which revealed the telomere length was critically short and fell at or below the first percentile for age, supporting the diagnosis. The liver biopsy showed marked portal inflammation with interface hepatitis, ductular reaction and frequent foci of lobular inflammation with focal hepatocyte dropout. Hepatocytes around the portal tracts demonstrated ballooning degeneration and occasional Mallory-Denk bodies. A trichrome stain highlighted bridging fibrosis. A literature review shows liver histology is available in only a small number of STS patients, demonstrating a variety of morphologic features. Our case and others suggest liver disease associated with STS exhibits a spectrum of histopathology. Being aware of these features is important for establishing the correct diagnosis of STS which is under recognized.
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Affiliation(s)
- Lixia Bai
- 5228University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Charles Rohrer
- 5228University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Yongjun Liu
- 5228University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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25
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Hercun J, Parikh E, Kleiner DE, Fuss I, Uzel G, Strober W, Koh C, Holland SM, Heller T. Recurrent Nodular Regenerative Hyperplasia Following Liver Transplantation in Common Variable Immunodeficiency. Hepatology 2021; 74:1698-1701. [PMID: 33638875 PMCID: PMC8390566 DOI: 10.1002/hep.31775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/15/2021] [Accepted: 02/05/2021] [Indexed: 12/07/2022]
Affiliation(s)
- Julian Hercun
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 20892, USA
| | - Esha Parikh
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 20892, USA
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD 20892, USA
| | - Ivan Fuss
- Mucosal Immunity Section, Bethesda, MD 20892, USA
| | - Gulbu Uzel
- Immunopathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | | | - Christopher Koh
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 20892, USA
| | - Steven M Holland
- Immunopathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Theo Heller
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 20892, USA
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26
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Thoré P, Jaïs X, Savale L, Dorfmuller P, Boucly A, Devilder M, Meyrignac O, Pichon J, Mankikian J, Riou M, Boiffard E, Boissin C, De Groote P, Chabanne C, Gagnadoux F, Bergeron A, Noel N, Sitbon O, Humbert M, Montani D. Pulmonary Hypertension in Patients with Common Variable Immunodeficiency. J Clin Immunol 2021; 41:1549-1562. [PMID: 34110542 DOI: 10.1007/s10875-021-01064-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/10/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Common variable immunodeficiency (CVID) is known to cause infectious, inflammatory, and autoimmune manifestations. Pulmonary hypertension (PH) is an unusual complication of CVID with largely unknown characteristics and mechanisms. METHODS We report the clinical, functional, hemodynamics, radiologic and histologic characteristics, and outcomes of CVID-associated PH patients from the French PH Network. RESULTS Ten patients were identified. The median (range) age at CVID diagnosis was 36.5 (4-49) years and the median delay between CVID and PH diagnosis was 12 (0-30) years. CVID-associated PH affected predominantly women (female-to-male ratio 9:1). Most patients were New York Heart Association functional class III with a severe hemodynamic profile and frequent portal hypertension (n = 6). Pulmonary function tests were almost normal in 70% of patients and showed a mild restrictive syndrome in 30% of patients while the diffusing capacity for carbon monoxide was decreased in all but one patient. High-resolution computed tomography found enlarged mediastinal nodes, mild interstitial infiltration with reticulations and nodules. Two patients had a CIVD-interstitial lung disease, and one presented with bronchiectasis. Pathologic assessment of lymph nodes performed in 5 patients revealed the presence of granulomas (n = 5) and follicular lymphoid hyperplasia (n = 3). At last follow-up (median 24.5 months), 9 patients were alive, and one patient died of Hodgkin disease. CONCLUSION PH is a possible complication of CVID whose pathophysiological mechanisms, while still unclear, would be due to the inflammatory nature of CVID. CVID-associated PH presents as precapillary PH with multiple possible causes, acting in concert in some patients: a portal hypertension, a pulmonary vascular remodeling, sometimes a pulmonary parenchymal involvement and occasionally an extrinsic compression by mediastinal lymphadenopathies, which would be consistent with its classification in group 5 of the current PH classification.
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Affiliation(s)
- Pierre Thoré
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Centre Hospitalier Régional Universitaire (CHRU) de Nancy, Department of Pneumology, Hôpital Brabois, Vandoeuvre-lès-Nancy, France.,INSERM UMR_S 1116 "Défaillance Cardiovasculaire Aigüe Et Chronique", School of Medicine of Nancy, University of Lorraine, Nancy, France
| | - Xavier Jaïs
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Laurent Savale
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Peter Dorfmuller
- Department of Pathology, University Hospital of Giessen and Marburg (UKGM), Giessen, Germany
| | - Athénaïs Boucly
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Matthieu Devilder
- School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Radiology, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olivier Meyrignac
- School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Radiology, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Jérémie Pichon
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Julie Mankikian
- Centre Hospitalier Régional Universitaire (CHRU) de Tours, Department of Pneumology, Hôpital Bretonneau, Tours, France
| | - Marianne Riou
- Department of Pneumology, Centre Hospitalier Universitaire (CHU) de Strasbourg, Nouvel Hôpital Civil (NHC) de Strasbourg, Strasbourg, France
| | - Emmanuel Boiffard
- Centre Hospitalier Départemental (CHD) de Vendée, Department of Cardiology, Hôpital de La Roche sur Yon, La Roche sur Yon, France
| | - Clément Boissin
- Centre Hospitalier Universitaire (CHU) de Montpellier, Department of Pneumology, Hôpital Arnaud de Villeneuve, Montpellier, France
| | - Pascal De Groote
- Centre Hospitalier Universitaire (CHU) de Lille, Department of Cardiology, Hôpital Albert Calmette, Lille, France.,Inserm U1167, Institut Pasteur de Lille, Lille, France
| | - Céline Chabanne
- Department of Cardiology and Vascular Diseases, Cardio-pneumologic Center, Centre Hospitalier Universitaire (CHU) de Rennes, Rennes, France
| | - Frédéric Gagnadoux
- Department of Pneumology, Centre Hospitalier Universitaire (CHU) D'Angers, Angers, France.,INSERM U1063, School of Medicine, Angers, France
| | - Anne Bergeron
- Université de Paris, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Pneumology, Hôpital Saint-Louis, Paris, France.,INSERM UMR_S 1153 "Centre de Recherche Épidémiologie Et Statistique Sorbonne Paris Cité (CRESS)", Hôpital Saint-Louis, Paris, France
| | - Nicolas Noel
- School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Internal Medicine and Immunology, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,UMR INSERM/CEA 1184, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Marc Humbert
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - David Montani
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France. .,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France. .,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
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27
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Drzewiecki K, Choi J, Brancale J, Leney-Greene MA, Sari S, Dalgiç B, Ünlüsoy Aksu A, Evirgen Şahin G, Ozen A, Baris S, Karakoc-Aydiner E, Jain D, Kleiner D, Schmalz M, Radhakrishnan K, Zhang J, Hoebe K, Su HC, Pereira JP, Lenardo MJ, Lifton RP, Vilarinho S. GIMAP5 maintains liver endothelial cell homeostasis and prevents portal hypertension. J Exp Med 2021; 218:212076. [PMID: 33956074 PMCID: PMC8105721 DOI: 10.1084/jem.20201745] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/20/2020] [Accepted: 04/02/2021] [Indexed: 01/04/2023] Open
Abstract
Portal hypertension is a major contributor to decompensation and death from liver disease, a global health problem. Here, we demonstrate homozygous damaging mutations in GIMAP5, a small organellar GTPase, in four families with unexplained portal hypertension. We show that GIMAP5 is expressed in hepatic endothelial cells and that its loss in both humans and mice results in capillarization of liver sinusoidal endothelial cells (LSECs); this effect is also seen when GIMAP5 is selectively deleted in endothelial cells. Single-cell RNA-sequencing analysis in a GIMAP5-deficient mouse model reveals replacement of LSECs with capillarized endothelial cells, a reduction of macrovascular hepatic endothelial cells, and places GIMAP5 upstream of GATA4, a transcription factor required for LSEC specification. Thus, GIMAP5 is a critical regulator of liver endothelial cell homeostasis and, when absent, produces portal hypertension. These findings provide new insight into the pathogenesis of portal hypertension, a major contributor to morbidity and mortality from liver disease.
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Affiliation(s)
- Kaela Drzewiecki
- Department of Internal Medicine (Digestive Diseases), Yale School of Medicine, New Haven, CT
| | - Jungmin Choi
- Department of Biomedical Sciences, Korea University College of Medicine, Seoul, Korea.,Department of Genetics, Yale School of Medicine, New Haven, CT
| | - Joseph Brancale
- Department of Internal Medicine (Digestive Diseases), Yale School of Medicine, New Haven, CT.,Department of Pathology, Yale School of Medicine, New Haven, CT
| | - Michael A Leney-Greene
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Sinan Sari
- Department of Pediatrics, Division of Gastroenterology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Buket Dalgiç
- Department of Pediatrics, Division of Gastroenterology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Aysel Ünlüsoy Aksu
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Health Sciences, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Gülseren Evirgen Şahin
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Health Sciences, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Ahmet Ozen
- Department of Pediatrics, Division of Allergy and Immunology, Marmara University School of Medicine, The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Safa Baris
- Department of Pediatrics, Division of Allergy and Immunology, Marmara University School of Medicine, The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Elif Karakoc-Aydiner
- Department of Pediatrics, Division of Allergy and Immunology, Marmara University School of Medicine, The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Dhanpat Jain
- Department of Pathology, Yale School of Medicine, New Haven, CT
| | - David Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Michael Schmalz
- Department of Pediatrics, Division of Gastroenterology, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Kadakkal Radhakrishnan
- Department of Pediatrics, Division of Gastroenterology, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Junhui Zhang
- Department of Genetics, Yale School of Medicine, New Haven, CT
| | | | - Helen C Su
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - João P Pereira
- Department of Immunobiology, Yale School of Medicine, New Haven, CT
| | - Michael J Lenardo
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Richard P Lifton
- Department of Genetics, Yale School of Medicine, New Haven, CT.,Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY
| | - Sílvia Vilarinho
- Department of Internal Medicine (Digestive Diseases), Yale School of Medicine, New Haven, CT.,Department of Pathology, Yale School of Medicine, New Haven, CT
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28
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Kmeid M, Liu X, Ballentine S, Lee H. Idiopathic Non-Cirrhotic Portal Hypertension and Porto-Sinusoidal Vascular Disease: Review of Current Data. Gastroenterology Res 2021; 14:49-65. [PMID: 34007347 PMCID: PMC8110235 DOI: 10.14740/gr1376] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/30/2021] [Indexed: 12/29/2022] Open
Abstract
Idiopathic non-cirrhotic portal hypertension (INCPH) is a clinicopathologic disease entity characterized by the presence of clinical signs and symptoms of portal hypertension (PH) in the absence of liver cirrhosis or known risk factors accountable for PH. Multiple hematologic, immune-related, infectious, hereditary and metabolic risk factors have been associated with this disorder. Still, the exact etiopathogenesis is largely unknown. The recently proposed porto-sinusoidal vascular disease (PSVD) scheme broadens the spectrum of the disease by also including patients without clinical PH who are found to have similar histopathologic findings on core liver biopsies. Three histomorphologic lesions have been identified as specific for PSVD to include obliterative portal venopathy, nodular regenerative hyperplasia and incomplete septal cirrhosis/fibrosis. However, these findings are often subtle, under-recognized and subjective with low interobserver agreement among pathologists. Additionally, the natural history of the subclinical forms of the disease remains unexplored. The clinical course is more favorable compared to cirrhosis patients, especially in the absence of clinical PH or liver dysfunction. There are no universally accepted guidelines in regard to diagnosis and treatment of INCPH/PSVD. Hence, this review emphasizes the need to raise awareness of this entity by highlighting its complex pathophysiology and clinicopathologic associations. Lastly, formulation of standardized diagnostic criteria with clinical validation is necessary to avoid misclassifying vascular diseases of the liver and to develop and implement targeted therapeutic strategies.
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Affiliation(s)
- Michel Kmeid
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA
| | - Xiuli Liu
- Department of Pathology and Laboratory Medicine, University of Florida at Gainesville, FL, USA
| | - Samuel Ballentine
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Hwajeong Lee
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA
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29
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Gao E, Hercun J, Heller T, Vilarinho S. Undiagnosed liver diseases. Transl Gastroenterol Hepatol 2021; 6:28. [PMID: 33824932 DOI: 10.21037/tgh.2020.04.04] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/19/2020] [Indexed: 02/06/2023] Open
Abstract
The landscape of chronic liver disease has drastically changed over the past 20 years, largely due to advances in antiviral therapy and the rise of metabolic syndrome and associated non-alcoholic fatty liver disease (NAFLD). Despite advances in the diagnosis and treatment of a variety of liver diseases, the burden of chronic liver disease is increasing worldwide. The first step to addressing any disease is accurate diagnosis. Here, we discuss liver diseases that remain undiagnosed, either because they are difficult to diagnose or due to hepatic manifestations of an unrecognized systemic disease. Additionally, their underlying etiology may remain unknown or they represent previously uncharacterized and therefore novel liver diseases. Our goal is to provide a framework for approaching undiagnosed liver diseases which elude standard hepatic diagnostic work-up and whose patterns of disease are often overlooked.
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Affiliation(s)
- Emily Gao
- Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Julian Hercun
- Translational Hepatology Section, National Institute of Diabetes & Digestive & Kidney Diseases, National Institute of Health, Bethesda, MD, USA
| | - Theo Heller
- Translational Hepatology Section, National Institute of Diabetes & Digestive & Kidney Diseases, National Institute of Health, Bethesda, MD, USA
| | - Sílvia Vilarinho
- Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA.,Department of Pathology, Yale School of Medicine, New Haven, CT, USA
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30
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Viallard JF, Lebail B, Begueret H, Fieschi C. [Common variable immunodeficiency disorders: Part 2. Updated clinical manifestations and therapeutic management]. Rev Med Interne 2021; 42:473-481. [PMID: 33516581 DOI: 10.1016/j.revmed.2020.12.015] [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: 07/03/2020] [Revised: 12/04/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
Common variable immunodeficiency disorders (CVID) are the most common symptomatic primary antibody deficiency in adults with an estimated prevalence of 1/25,000. The most frequent clinical manifestations are upper respiratory tract infections (including pneumonia, bronchitis, and sinusitis) predominantly with Streptococcus pneumoniae or H. influenzae. However, CVID are complicated in 20 to 30 % of cases of non-infectious manifestations which have been well characterized in recent years. Several complications can be observed including autoimmune, lymphoproliferative, granulomatous or cancerous manifestations involving one or more organs. These complications, mostly antibody-mediated cytopenias, are correlated with a decrease in the number of circulating switched memory B cells. Replacement therapy with polyvalent gammaglobulins has greatly improved the prognosis of these patients but it remains poor in the presence of digestive complications (especially in the case of chronic enteropathy and/or porto-sinusoidal vascular disease), pulmonary complications (bronchiectasis and/or granulomatous lymphocytic interstitial lung disease) and when progression to lymphoma. Much progress is still to be made, in particular on the therapeutic management of non-infectious complications which should benefit in the future from targeted treatments based on knowledge of genetics and immunology.
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Affiliation(s)
- J F Viallard
- Service de médecine interne et maladies infectieuses, hôpital Haut-Lévêque, CHU de Bordeaux, 5, avenue de Magellan, 33604 Pessac, France; Université de Bordeaux, Bordeaux, France.
| | - B Lebail
- Université de Bordeaux, Bordeaux, France; Service d'anatomopathologie, hôpital Pellegrin, place Amélie-Rabat-Léon, 33076 Bordeaux, France
| | - H Begueret
- Service d'anatomopathologie, CHU Bordeaux, hôpital Haut-Lévêque, 5, avenue de Magellan, 33604 Pessac, France
| | - C Fieschi
- Département d'immunologie, université de Paris, AP-HP, France; INSERM U1126, centre Hayem, hôpital Saint-Louis, Paris, France
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31
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Perspective: Evolving Concepts in the Diagnosis and Understanding of Common Variable Immunodeficiency Disorders (CVID). Clin Rev Allergy Immunol 2021; 59:109-121. [PMID: 31720921 DOI: 10.1007/s12016-019-08765-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Common variable immunodeficiency disorders (CVID) are the most frequent symptomatic primary immune deficiency in adults. At this time, the causes of these conditions are unknown. Patients with CVID experience immune system failure consequent to late onset antibody failure. They have increased susceptibility to infections and are also at risk of severe autoimmune and inflammatory disorders as a result of immune dysregulation. An increasing number of monogenic causes as well as a digenic disorder have been described in patients with a CVID phenotype. If a causative mutation is identified, patients are removed from the umbrella diagnosis of CVID and are reclassified as having a CVID-like disorder, resulting from a specific mutation. In non-consanguineous populations, next-generation sequencing (NGS) identifies a genetic cause in approximately 25% of patients with a CVID phenotype. It is six years since we published our diagnostic criteria for CVID. There is ongoing debate about diagnostic criteria, the role of vaccine responses and genetic analysis in the diagnosis of CVID. There have been several recent studies, which have addressed some of these uncertainties. Here we review this new evidence from the perspective of our CVID diagnostic criteria and speculate on future approaches, which may assist in identifying and assessing this group of enigmatic disorders.
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32
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Li Y, Xu C, Lin N, Zhao Y, Song J. Nodular regenerative hyperplasia and portal hypertension are the characteristics of liver abnormalities in patients with selective immunoglobulin A deficiency. Clin Res Hepatol Gastroenterol 2020; 44:e123-e125. [PMID: 32146091 DOI: 10.1016/j.clinre.2020.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/14/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Yang Li
- Department of Critical Care Medicine, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, 110004 Shenyang, Liaoning, PR China
| | - Can Xu
- Department of Pathology, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, 110004 Shenyang, Liaoning, PR China
| | - Nan Lin
- Department of Radiology, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, 110004 Shenyang, Liaoning, PR China
| | - Yue Zhao
- Hematology Laboratory, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, 110004 Shenyang, Liaoning, PR China
| | - Junmin Song
- Department of Gastroenterology, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, 110004 Shenyang, Liaoning, PR China.
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33
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Abstract
Common variable immunodeficiency (CVID) has a heterogenous clinical presentation and can be challenging to diagnose. Distinct histologic changes have been linked with CVID in several organ systems, which can help identify the correct diagnosis. In this study we review a cohort of hepatic CVID biopsies, to better define the spectrum of histologic and biochemical alterations. We reviewed 26 liver biopsies from 24 patients with CVID, obtained at 4 institutions between 2010 and 2019. Histologic slides were examined, and pathologic, biochemical, and clinical features were recorded. A control cohort of 21 patients with nodular regenerative hyperplasia (NRH) but lacking CVID was also examined. Liver function tests were frequently abnormal, especially alkaline phosphatase (median: 193 IU/L) and aspartate transaminase (median: 56 U/L), elevated in 23 and 17 of 25 biopsies, respectively. Fifteen patients had CVID involvement of other organs. Histologic features of primary biliary cholangitis were present in 2 patients, with florid duct lesions and prominent bile duct injury, in association with positive antimitochondrial antibodies. Among the other 24 biopsies, mild to moderate portal and lobular inflammation were present in 18 and 17 of 24 biopsies, respectively. Overall, 22 of 24 biopsies showed NRH-like changes. Plasma cell were absent. A distinct pattern of pericellular fibrosis was present in 23 of 26 biopsies overall. Involvement ranged from focal centrizonal fibrosis to bridging fibrosis and was accompanied by increased intrasinusoidal lymphocytes in 13 of 24 biopsies. Pericellular fibrosis was identified in 1 of 21 biopsies in the control cohort. Additional findings included granulomatous inflammation or nonhepatocellular foreign body-type multinucleate giant cells, identified in 4 biopsies. Three of 6 examined biopsies also demonstrated focal hepatocellular copper deposition. Hepatic disease in CVID is often associated with elevated alkaline phosphatase and aspartate transaminase and is characterized histologically by the mild nonspecific portal and lobular hepatitis, absence of plasma cells, NRH-like changes, and less commonly, typical histologic features of primary biliary cholangitis. We have also identified a distinctive pattern of delicate pericellular fibrosis that is a helpful clue to the diagnosis of hepatic disease in CVID, especially when accompanied by NRH-like changes.
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34
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Ameratunga R, Allan C, Woon ST. Defining Common Variable Immunodeficiency Disorders in 2020. Immunol Allergy Clin North Am 2020; 40:403-420. [PMID: 32654689 DOI: 10.1016/j.iac.2020.03.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Common variable immunodeficiency disorders (CVID) are the most frequent symptomatic primary immune deficiency in adults. Because there is no known cause for these conditions, there is no single clinical feature or laboratory test that can confirm the diagnosis with certainty. If a causative mutation is identified, patients are deemed to have a CVID-like disorder caused by a specific primary immunodeficiency/inborn error of immunity. In the remaining patients, the explanation for these disorders remains unclear. The understanding of CVID continues to evolve and the authors review recent studies, which have addressed some of these uncertainties.
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Affiliation(s)
- Rohan Ameratunga
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand; Auckland Healthcare Services, Park Road, Grafton, Auckland 1010, New Zealand; Clinical Immunology, Auckland City Hospital, Auckland, New Zealand; Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Caroline Allan
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand; Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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35
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De Gottardi A, Rautou PE, Schouten J, Rubbia-Brandt L, Leebeek F, Trebicka J, Murad SD, Vilgrain V, Hernandez-Gea V, Nery F, Plessier A, Berzigotti A, Bioulac-Sage P, Primignani M, Semela D, Elkrief L, Bedossa P, Valla D, Garcia-Pagan JC. Porto-sinusoidal vascular disease: proposal and description of a novel entity. Lancet Gastroenterol Hepatol 2020; 4:399-411. [PMID: 30957754 DOI: 10.1016/s2468-1253(19)30047-0] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/16/2019] [Accepted: 01/17/2019] [Indexed: 12/14/2022]
Abstract
Portal hypertension in the absence of portal vein thrombosis and without cirrhosis, but with mild or moderate alterations of liver histology (eg, obliterative venopathy, nodular regenerative hyperplasia, or incomplete septal cirrhosis) is being increasingly recognised. Owing to the heterogeneity of causes and histological findings, a substantial number of terms have been used to describe such idiopathic non-cirrhotic portal hypertension. Patients with the same clinical and histological features exist, but without portal hypertension at the time of diagnosis. Therefore, improved criteria are needed to define this form of liver disease. Here, we propose the term porto-sinusoidal vascular disease, since all lesions found involve the portal venules or sinusoids. The definition of this entity is based on the characteristic absence of cirrhosis with or without signs of portal hypertension or histological lesions. The presence of known causes of liver disease does not rule out porto-sinusoidal vascular disease, but specific causes of vascular liver disease are excluded from its definition. The diagnosis of porto-sinusoidal vascular disease is based on liver biopsy and might include signs specific for portal hypertension with normal or mildly elevated liver stiffness values and no complete portal vein thrombosis. We provide simple diagnostic criteria, because agreement on a uniform nomenclature is an essential requirement for future collaborative studies.
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Affiliation(s)
- Andrea De Gottardi
- University Clinic for Visceral Surgery and Medicine, Inselspital, Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, Hôpital Beaujon, Clichy, France; Centre de Recherche de l'Inflammation, Inserm and Université Paris Diderot, Paris, France
| | | | - Laura Rubbia-Brandt
- Service de Pathologie Clinique, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Frank Leebeek
- Department of Haematology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany; European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain; CIBER Hepatic and Digestive Diseases, Instituto de Salud Carlos III, Madrid, Spain
| | - Filipe Nery
- Centro Hospitalar Universitário and EpiUnit, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Aurélie Plessier
- Service d'Hépatologie, Hôpital Beaujon, Clichy, France; Centre de Recherche de l'Inflammation, Inserm and Université Paris Diderot, Paris, France
| | - Annalisa Berzigotti
- University Clinic for Visceral Surgery and Medicine, Inselspital, Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | | | - Massimo Primignani
- Gastroenterologia ed Epatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - David Semela
- Gastroenterology and Hepatology, Kantonsspital, St Gallen, Switzerland
| | - Laure Elkrief
- Hepatology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Dominique Valla
- Service d'Hépatologie, Hôpital Beaujon, Clichy, France; Centre de Recherche de l'Inflammation, Inserm and Université Paris Diderot, Paris, France
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain; CIBER Hepatic and Digestive Diseases, Instituto de Salud Carlos III, Madrid, Spain.
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36
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Pecoraro A, Crescenzi L, Varricchi G, Marone G, Spadaro G. Heterogeneity of Liver Disease in Common Variable Immunodeficiency Disorders. Front Immunol 2020; 11:338. [PMID: 32184784 PMCID: PMC7059194 DOI: 10.3389/fimmu.2020.00338] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/11/2020] [Indexed: 12/13/2022] Open
Abstract
Common variable immunodeficiency (CVID) is the most frequent primary immunodeficiency (PID) in adulthood and is characterized by severe reduction of immunoglobulin serum levels and impaired antibody production in response to vaccines and pathogens. Beyond the susceptibility to infections, CVID encompasses a wide spectrum of clinical manifestations related to a complex immune dysregulation that also affects liver. Although about 50% CVID patients present persistently deranged liver function, burden, and nature of liver involvement have not been systematically investigated in most cohort studies published in the last decades. Therefore, the prevalence of liver disease in CVID widely varies depending on the study design and the sampling criteria. This review seeks to summarize the evidence about the most relevant causes of liver involvement in CVID, including nodular regenerative hyperplasia (NRH), infections and malignancies. We also describe the clinical features of liver disease in some monogenic forms of PID included in the clinical spectrum of CVID as ICOS, NFKB1, NFKB2, CTLA-4, PI3Kδ pathway, ADA2, and IL21-R genetic defects. Finally, we discuss the clinical applications of the various diagnostic tools and the possible therapeutic approaches for the management of liver involvement in the context of CVID.
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Affiliation(s)
- Antonio Pecoraro
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Ludovica Crescenzi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research, WAO Center of Excellence, University of Naples Federico II, Naples, Italy
| | - Giancarlo Marone
- Department of Public Health, University of Naples Federico II, Naples, Italy.,Monaldi Hospital, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research, WAO Center of Excellence, University of Naples Federico II, Naples, Italy
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37
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Lee WI, Fan WL, Lu CH, Chen SH, Kuo ML, Lin SJ, Tsai WS, Jaing TH, Chen LC, Yeh KW, Yao TC, Huang JL. A Novel CD3G Mutation in a Taiwanese Patient With Normal T Regulatory Function Presenting With the CVID Phenotype Free of Autoimmunity-Analysis of all Genotypes and Phenotypes. Front Immunol 2019; 10:2833. [PMID: 31921117 PMCID: PMC6930882 DOI: 10.3389/fimmu.2019.02833] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 11/18/2019] [Indexed: 12/03/2022] Open
Abstract
The T-cell receptor (TCR)/CD3 complex is crucial for T-cell development and regulation. In humans, CD3D, CD3E, and CD3Z gene defects cause severe combined T- and B-cell immunodeficiency. However, CD3G mutations alone lead to a less severe condition, which is mainly characterized by autoimmunity. In the present study, we report the case of a 36-year-old male who presented with recurrent sinopulmonary infections without opportunistic infections; this was compatible with hypogammaglobulinemia, but normal PHA-lymphocyte proliferation. This patient had the common variable immunodeficiency (CVID) phenotype and received regular immunoglobulin infusions over 20-years; he gradually developed nodular regenerative hyperplasia over a 5-year period. Distinct from the previously reported CD3G mutations, which mainly present as autoimmunity, the novel CD3G deletion (c.del213A) in our patient caused an obvious decrease in switched memory B cells and diminished CD40L expression. However, sufficient Treg suppression function was maintained so that he remained free of autoimmune thyroiditis (AIT), inflammatory bowel disease (IBD), and autoimmune pancytopenia. A PubMed search for this rare disease entity revealed seven Turkish and two Spanish patients (five unrelated families). Among a total of 20 alleles, there were 14 splicing mutations (80(-1)G>C), two missense mutations (c.1G>A), two nonsense mutations (c.250A>T), and two deletions (c.del213A). Three patients presented with isolated AIT without significant infections. Three patients died, one from a severe infection at 31 months, one from post-transplant respiratory failure due to viral pneumonia at 17 months, and one from graft-vs.-host disease at 47 months. Those experiencing opportunistic infections, severe life-threatening infections in need of hematopoietic stem cell transplantation, and IBD-like diarrhea had a significantly higher mortality rate compared with those without these features (p = 0.0124, p = 0.01, and p = 0.0124, respectively). The patients with AIT had a significantly better prognosis (p = 0.0124) to those without AIT. Our patient with the novel CD3G mutation presented with predominant B-cell deficiency overlapping with the CVID phenotype but without recognizable autoimmunity, which was consistent with his normal Treg suppression function.
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Affiliation(s)
- Wen-I Lee
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Primary Immunodeficiency Care and Research (PICAR) Institute, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Lang Fan
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chun-Hao Lu
- Department of Microbiology and Immunology, Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Hsiang Chen
- Primary Immunodeficiency Care and Research (PICAR) Institute, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Division of Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Ling Kuo
- Department of Microbiology and Immunology, Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Syh-Jae Lin
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Weng-Sheng Tsai
- Division of Nephronology, Department of Medicine, Penghu Hospital, Ministry of Health and Welfare, Penghu, Taiwan
| | - Tang-Her Jaing
- Primary Immunodeficiency Care and Research (PICAR) Institute, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Division of Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Li-Chen Chen
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kuo-Wei Yeh
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tsung-Chieh Yao
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jing-Long Huang
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Primary Immunodeficiency Care and Research (PICAR) Institute, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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38
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Crescenzi L, Pecoraro A, Fiorentino A, Poto R, Varricchi G, Rispo A, Morisco F, Spadaro G. Liver stiffness assessment by transient elastography suggests high prevalence of liver involvement in common variable immunodeficiency. Dig Liver Dis 2019; 51:1599-1603. [PMID: 31155490 DOI: 10.1016/j.dld.2019.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/06/2019] [Accepted: 05/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Up to 50% of patients with common variable immunodeficiency (CVID) present persistently increased serum levels of liver enzymes and/or mild hepatomegaly. Ultrasound-based transient elastography (TE) is largely used for early detection of the progression of chronic liver diseases, but has never been employed in CVID. We performed a cross-sectional study to evaluate TE values in a cohort of adult CVID-patients. METHODS Full blood count, liver function test, liver and spleen sonogram and ultrasound-based TE were performed in 77 adult CVID patients. Demographic and clinical data were retrospectively collected from medical files. RESULTS 33.8% (26/77) patients presented increased TE values ranging from moderate fibrosis to cirrhosis. TE values were positively correlated with ALP, γGT, spleen longitudinal diameter and peripheral blood counts (no significant correlation with BMI, AST, ALT, total proteins, albumin, bilirubin and hemoglobin). Moreover, liver stiffness was higher in patients with the clinical phenotypes polyclonal lymphoproliferation and enteropathy, and patients with both these complications had an increased risk (OR: 7.14) of presenting pathologic TE values compared with those without anyone of these. CONCLUSIONS Transient elastography is a useful tool to be used alongside clinical and laboratory data to assess liver involvement in CVID.
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Affiliation(s)
- Ludovica Crescenzi
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Antonio Pecoraro
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Andrea Fiorentino
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Remo Poto
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Antonio Rispo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Filomena Morisco
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.
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39
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Abstract
This article presents the most common gastrointestinal, hepatic, and pancreatic manifestations of the primary immunodeficiency diseases, including the appropriate laboratory testing, endoscopic evaluation, and recommendations for further management.
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Affiliation(s)
| | - Sarah Glover
- UF Health, PO Box 103643, Gainesville, FL 32610, USA.
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40
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Liver disease is common in patients with common variable immunodeficiency and predicts mortality in the presence of cirrhosis or portal hypertension. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2484-2486.e3. [PMID: 31026542 DOI: 10.1016/j.jaip.2019.04.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/28/2019] [Accepted: 04/09/2019] [Indexed: 12/26/2022]
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41
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Apostolov R, Sinclair M, Lokan J, Angus P. Successful liver transplantation in common variable immune deficiency with reversal of hepatopulmonary syndrome. BMJ Case Rep 2019; 12:12/4/e226095. [PMID: 30948390 DOI: 10.1136/bcr-2018-226095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Common variable immune deficiency (CVID) is a primary immunodeficiency disorder that is associated with abnormal liver function tests, however advanced liver disease is uncommon. Hepatopulmonary syndrome (HPS) is a rare but debilitating complication of CVID-associated liver disease. We report a case of CVID complicated by HPS that was successfully treated with orthotopic liver transplant, with the patient recovering to normal hepatic function and successfully weaning off domiciliary oxygen post-transplantation.
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Affiliation(s)
- Ross Apostolov
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Julie Lokan
- Department of Pathology, Austin Health, Heidelberg, Victoria, Australia
| | - Peter Angus
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
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42
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Cunningham-Rundles C. Common variable immune deficiency: Dissection of the variable. Immunol Rev 2019; 287:145-161. [PMID: 30565247 PMCID: PMC6435035 DOI: 10.1111/imr.12728] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/16/2018] [Indexed: 12/28/2022]
Abstract
Starting about 60 years ago, a number of reports appeared that outlined the severe clinical course of a few adult subjects with profound hypogammaglobinemia. Puzzled by the lack of family history and adult onset of symptoms in most, the name "acquired" hypogammaglobinemia was given, but later altered to the current name common variable immune deficiency. Pathology reports remarked on the loss of lymph node architecture and paucity of plasma cells in lymphoid tissues in these subjects. While characterized by reduced serum IgG and IgA and often IgM, and thus classified among the B-cell defects, an increasing number of cellular defects in these patients have been recognized over time. In the early years, severe respiratory tract infections commonly led to a shortened life span, but the wide spread availability of immune globulin concentrates for the last 25 years has improved survival. However, chronic non-infectious inflammatory and autoimmune conditions have now emerged as challenging clinical problems; these require further immunologic understanding and additional therapeutic measures. Recent study of this phenotypic syndrome have provided an increasingly fertile ground for the identification of autosomal recessive and now more commonly, autosomal dominant gene defects which lead to the loss of B-cell development in this syndrome.
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43
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Song J, Lleo A, Yang GX, Zhang W, Bowlus CL, Gershwin ME, Leung PSC. Common Variable Immunodeficiency and Liver Involvement. Clin Rev Allergy Immunol 2018; 55:340-351. [PMID: 28785926 PMCID: PMC5803456 DOI: 10.1007/s12016-017-8638-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Common variable immunodeficiency (CVID) is a primary B-cell immunodeficiency disorder, characterized by remarkable hypogammaglobulinemia. The disease can develop at any age without gender predominance. The prevalence of CVID varies widely worldwide. The underlying causes of CVID remain largely unknown; primary B-cell dysfunctions, defects in T cells and antigen-presenting cells are involved. Although some monogenetic defects have been identified in some CVID patients, it is likely that CVID is polygenic. Patients with CVID develop recurrent and chronic infections (e.g., bacterial infections of the respiratory or gastrointestinal tract), autoimmune diseases, lymphoproliferation, malignancies, and granulomatous lesions. Interestingly, autoimmunity can be the only clinical manifestation of CVID at the time of diagnosis and may even develop prior to hypogammaglobulinemia. The diagnosis of CVID is largely based on the criteria established by European Society for Immunodeficiencies and Pan-American Group for Immunodeficiency (ESID/PAGID) and with some recent modifications. The disease can affect multiple organs, including the liver. Clinical features of CVID patients with liver involvement include abnormal liver biochemistries, primarily elevation of alkaline phosphatase (ALP), nodular regenerative hyperplasia (NRH), or liver cirrhosis and its complications. Replacement therapy with immunoglobulin (Ig) and anti-infection therapy are the primary treatment regimen for CVID patients. No specific therapy for liver involvement of CVID is currently available, and liver transplantation is an option only in select cases. The prognosis of CVID varies widely. Further understanding in the etiology and pathophysiology will facilitate early diagnosis and treatments to improve prognosis.
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Affiliation(s)
- Junmin Song
- Division of Rheumatology/Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Davis, CA, 95616, USA
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, People's Republic of China
| | - Ana Lleo
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Guo Xiang Yang
- Division of Rheumatology/Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Davis, CA, 95616, USA
| | - Weici Zhang
- Division of Rheumatology/Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Davis, CA, 95616, USA
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California, Davis, CA, 95616, USA
| | - M Eric Gershwin
- Division of Rheumatology/Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Davis, CA, 95616, USA
| | - Patrick S C Leung
- Division of Rheumatology/Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Davis, CA, 95616, USA.
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44
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Hernández-Gea V, Baiges A, Turon F, Garcia-Pagán JC. Idiopathic Portal Hypertension. Hepatology 2018; 68:2413-2423. [PMID: 30066417 DOI: 10.1002/hep.30132] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/16/2018] [Indexed: 12/12/2022]
Abstract
Idiopathic portal hypertension (IPH) is a rare disorder characterized by clinical portal hypertension in the absence of a recognizable cause such as cirrhosis. Laboratory tests often reveal a preserved liver function with anemia, leukopenia, and thrombocytopenia due to splenomegaly. Imaging studies reveal signs of portal hypertension, whereas liver stiffness and portal pressure values are usually normal or slightly elevated. Liver biopsy is considered mandatory in order to rule out other causes of portal hypertension, mainly cirrhosis. Liver histology may only show subtle or mild changes, and the definite diagnosis of IPH often requires an expert pathologist and a high-quality specimen. The most frequent clinical presentation is variceal bleeding. Ascites is rarely observed initially, although it may occasionally appear during follow-up. Typical histological findings associated with IPH have been described in patients without portal hypertension, probably representing early stages of the disease. Although the pathophysiology of this entity remains largely unknown, it is frequently associated with underlying immunological disorders, bacterial infections, trace metal poisoning, medications, liver circulatory disturbances, and thrombotic events. The long-term prognosis of patients with IPH, where ascites and the underlying condition are important prognostic factors, is better than in patients with cirrhosis. Treatments that modify the natural history of the disease remain an unmet need, and management of IPH is frequently restricted to control of portal hypertension-related complications.
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Affiliation(s)
- Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Anna Baiges
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Juan Carlos Garcia-Pagán
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,University of Barcelona, Barcelona, Spain
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45
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Abstract
Hepatic granulomas are encountered in approximately 2% to 10% of liver biopsies. There are many potential infectious and noninfectious causes; granulomas can be generally classified by their morphology, which may be helpful in refining the differential diagnosis. This article provides a review of hepatic granulomas with an emphasis on infectious causes.
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Affiliation(s)
- Eun-Young Karen Choi
- Department of Pathology, University of Michigan, University of Michigan, 5231B Medical Science I, 1301 Catherine Street, SPC 5602, Ann Arbor, MI 48109, USA.
| | - Laura W Lamps
- Department of Pathology, University of Michigan, University of Michigan, 5231B Medical Science I, 1301 Catherine Street, SPC 5602, Ann Arbor, MI 48109, USA
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46
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Ben-Yakov G, Kapuria D, Marko J, Cho MH, Pittaluga S, Kleiner DE, Koh C, Holland S, Uzel G, Heller T. Liver disturbances in activated phosphoinositide 3-kinase δ syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:1763-1765. [PMID: 29378322 PMCID: PMC8108071 DOI: 10.1016/j.jaip.2018.01.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 01/16/2018] [Accepted: 01/16/2018] [Indexed: 11/20/2022]
Affiliation(s)
- Gil Ben-Yakov
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Md.
| | - Devika Kapuria
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Md
| | - Jamie Marko
- Radiology & Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Md
| | - Min Ho Cho
- Medstar Washington Hospital Center, Washington, DC
| | - Stefania Pittaluga
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Md
| | - David Erwin Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Md
| | - Christopher Koh
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Md
| | - Steven Holland
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Gulbu Uzel
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Theo Heller
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Md
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47
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Poisson J, Lemoinne S, Boulanger C, Durand F, Moreau R, Valla D, Rautou PE. Liver sinusoidal endothelial cells: Physiology and role in liver diseases. J Hepatol 2017; 66:212-227. [PMID: 27423426 DOI: 10.1016/j.jhep.2016.07.009] [Citation(s) in RCA: 574] [Impact Index Per Article: 82.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 07/05/2016] [Accepted: 07/07/2016] [Indexed: 12/13/2022]
Abstract
Liver sinusoidal endothelial cells (LSECs) are highly specialized endothelial cells representing the interface between blood cells on the one side and hepatocytes and hepatic stellate cells on the other side. LSECs represent a permeable barrier. Indeed, the association of 'fenestrae', absence of diaphragm and lack of basement membrane make them the most permeable endothelial cells of the mammalian body. They also have the highest endocytosis capacity of human cells. In physiological conditions, LSECs regulate hepatic vascular tone contributing to the maintenance of a low portal pressure despite the major changes in hepatic blood flow occurring during digestion. LSECs maintain hepatic stellate cell quiescence, thus inhibiting intrahepatic vasoconstriction and fibrosis development. In pathological conditions, LSECs play a key role in the initiation and progression of chronic liver diseases. Indeed, they become capillarized and lose their protective properties, and they promote angiogenesis and vasoconstriction. LSECs are implicated in liver regeneration following acute liver injury or partial hepatectomy since they renew from LSECs and/or LSEC progenitors, they sense changes in shear stress resulting from surgery, and they interact with platelets and inflammatory cells. LSECs also play a role in hepatocellular carcinoma development and progression, in ageing, and in liver lesions related to inflammation and infection. This review also presents a detailed analysis of the technical aspects relevant for LSEC analysis including the markers these cells express, the available cell lines and the transgenic mouse models. Finally, this review provides an overview of the strategies available for a specific targeting of LSECs.
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Affiliation(s)
- Johanne Poisson
- INSERM, UMR-970, Paris Cardiovascular Research Center - PARCC, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Sara Lemoinne
- INSERM, UMRS 938, Centre de Recherche Saint-Antoine, Université Pierre et Marie Curie Paris 6, Paris, France; Service d'hépatologie, Hôpital Saint-Antoine, APHP, Paris, France
| | - Chantal Boulanger
- INSERM, UMR-970, Paris Cardiovascular Research Center - PARCC, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - François Durand
- Service d'hépatologie, DHU Unity Hôpital Beaujon, APHP, Clichy, France; INSERM, UMR-1149, Centre de Recherche sur l'inflammation, Paris-Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, 75018 Paris, France
| | - Richard Moreau
- Service d'hépatologie, DHU Unity Hôpital Beaujon, APHP, Clichy, France; INSERM, UMR-1149, Centre de Recherche sur l'inflammation, Paris-Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, 75018 Paris, France
| | - Dominique Valla
- Service d'hépatologie, DHU Unity Hôpital Beaujon, APHP, Clichy, France; INSERM, UMR-1149, Centre de Recherche sur l'inflammation, Paris-Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, 75018 Paris, France
| | - Pierre-Emmanuel Rautou
- INSERM, UMR-970, Paris Cardiovascular Research Center - PARCC, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Service d'hépatologie, DHU Unity Hôpital Beaujon, APHP, Clichy, France; INSERM, UMR-1149, Centre de Recherche sur l'inflammation, Paris-Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, 75018 Paris, France.
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48
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Milligan KL, Schirm K, Leonard S, Hussey AA, Agharahimi A, Kleiner DE, Fuss I, Lingala S, Heller T, Rosenzweig SD. Ataxia telangiectasia associated with nodular regenerative hyperplasia. J Clin Immunol 2016; 36:739-742. [PMID: 27671921 DOI: 10.1007/s10875-016-0334-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 09/05/2016] [Indexed: 01/22/2023]
Affiliation(s)
- Ki L Milligan
- Laboratory of Infectious Diseases, NIAID, NIH, Bethesda, MD, USA.,Primary Immunodeficiency Clinic, NIAID, NIH, Building 10, Room 2C410, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Karen Schirm
- Laboratory of Infectious Diseases, NIAID, NIH, Bethesda, MD, USA
| | - Stephanie Leonard
- Division of Allergy and Immunology, University of California, San Diego, Rady Children's Hospital, San Diego, CA, USA
| | - Ashleigh A Hussey
- Primary Immunodeficiency Clinic, NIAID, NIH, Building 10, Room 2C410, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Anahita Agharahimi
- Primary Immunodeficiency Clinic, NIAID, NIH, Building 10, Room 2C410, 10 Center Drive, Bethesda, MD, 20892, USA
| | | | - Ivan Fuss
- Mucosal Immunity Section, NIAID NIH, Bethesda, MD, USA
| | | | - Theo Heller
- Liver Diseases Branch, NIDDK, NIH, Bethesda, MD, USA
| | - Sergio D Rosenzweig
- Primary Immunodeficiency Clinic, NIAID, NIH, Building 10, Room 2C410, 10 Center Drive, Bethesda, MD, 20892, USA. .,Immunology Service, Department of Laboratory Medicine, Clinical Center, NIH, Building 10, Room 2C410, 10 Center Drive, Bethesda, MD, 20892, USA.
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49
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Riggio O, Gioia S, Pentassuglio I, Nicoletti V, Valente M, d’Amati G. Idiopathic noncirrhotic portal hypertension: current perspectives. Hepat Med 2016; 8:81-8. [PMID: 27555800 PMCID: PMC4968980 DOI: 10.2147/hmer.s85544] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The term idiopathic noncirrhotic portal hypertension (INCPH) has been recently proposed to replace terms, such as hepatoportal sclerosis, idiopathic portal hypertension, incomplete septal cirrhosis, and nodular regenerative hyperplasia, used to describe patients with a hepatic presinusoidal cause of portal hypertension of unknown etiology, characterized by features of portal hypertension (esophageal varices, nonmalignant ascites, porto-venous collaterals), splenomegaly, patent portal, and hepatic veins and no clinical and histological signs of cirrhosis. Physicians should learn to look for this condition in a number of clinical settings, including cryptogenic cirrhosis, a disease known to be associated with INCPH, drug administration, and even chronic alterations in liver function tests. Once INCPH is clinically suspected, liver histology becomes mandatory for the correct diagnosis. However, pathologists should be familiar with the histological features of INCPH, especially in cases in which histology is not only requested to exclude liver cirrhosis.
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Affiliation(s)
- Oliviero Riggio
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension
| | - Stefania Gioia
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension
| | - Ilaria Pentassuglio
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension
| | - Valeria Nicoletti
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension
| | - Michele Valente
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Giulia d’Amati
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
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Ameratunga R, Storey P, Barker R, Jordan A, Koopmans W, Woon ST. Application of diagnostic and treatment criteria for common variable immunodeficiency disorder. Expert Rev Clin Immunol 2016; 12:257-66. [PMID: 26623716 DOI: 10.1586/1744666x.2016.1126509] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Common variable immunodeficiency disorder (CVID) is the most frequent symptomatic primary immune deficiency disorder in adults. It probably comprises a spectrum of polygenic disorders, with hypogammaglobulinemia being the overarching feature. While the majority of patients with CVID can be identified with relative ease, a significant proportion can present with minimal symptoms in spite of profound laboratory abnormalities. Here we discuss three patients who were presented to the Auckland Hospital immunoglobulin treatment committee to determine if they qualified for immunoglobulin replacement. Two were asymptomatic with profound laboratory abnormalities while the third patient was severely ill with extensive bronchiectasis. The third patient had less severe laboratory abnormalities compared with the two asymptomatic patients. We have applied four sets of published diagnostic and treatment criteria to these patients to compare their clinical utility. We have chosen these patients from the broad phenotypic spectrum of CVID, as this often illustrates differences in diagnostic and treatment criteria.
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Affiliation(s)
- Rohan Ameratunga
- a Department of Virology and Immunology , Auckland Hospital , Auckland , New Zealand.,b Clinical Immunology , Auckland Hospital , Auckland , New Zealand
| | - Peter Storey
- b Clinical Immunology , Auckland Hospital , Auckland , New Zealand
| | - Russell Barker
- a Department of Virology and Immunology , Auckland Hospital , Auckland , New Zealand
| | - Anthony Jordan
- b Clinical Immunology , Auckland Hospital , Auckland , New Zealand
| | - Wikke Koopmans
- a Department of Virology and Immunology , Auckland Hospital , Auckland , New Zealand
| | - See-Tarn Woon
- a Department of Virology and Immunology , Auckland Hospital , Auckland , New Zealand
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