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Staicu A, Popa-Stanila R, Albu C, Chira A, Constantin R, Boitor-Borza D, Surcel M, Rotar IC, Cruciat G, Muresan D. Neonatal Hemochromatosis: Systematic Review of Prenatal Ultrasound Findings—Is There a Place for MRI in the Diagnostic Process? J Clin Med 2023; 12:jcm12072679. [PMID: 37048762 PMCID: PMC10094906 DOI: 10.3390/jcm12072679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/24/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023] Open
Abstract
Neonatal hemochromatosis (NH) is an uncommon, severe disorder that results in fetal loss or neonatal death due to liver failure. NH is currently regarded as the phenotypic expression of gestational alloimmune liver disease (GALD). The diagnosis of NH-GALD is rarely prenatally established. In addition to providing a systematic review of the prenatal features that are identifiable using ultrasound (US) and MRI, we suggest a prenatal diagnosis algorithm for use in suspected NH during the first affected pregnancy. From a total of 586 database entries identified in PubMed, Google Scholar, and ResearchGate, we selected 18 studies published from 1993 to 2021 that reported maternal medical and obstetric history, prenatal ultrasound findings, and postpartum outcomes. We investigated the ultrasound and MRI features of these studies, along with the outcome due to this condition. A total of 74 cases were identified. The main reported prenatal US finding was fetal growth restriction (FGR) (33%), followed by oligohydramnios (13%) and hydrops fetalis (13%), with 13% cases described as uneventful. Other rare prenatal findings were fetal anemia, ascites, and abnormal fetal liver and spleen. Most pregnancies ended with fetal/perinatal death or therapeutic interruption of pregnancy. Favorable evolution with treatment (ensanguine transfusion and intravenous immunoglobulin (IVIG)) was reported for only 7% of fetuses. Using T2-weighted MRI, fetal extrahepatic siderosis confirmed prenatally in two cases and postnatally in 11 cases. IVIG treatment throughout subsequent pregnancies was found to significantly improve fetal prognosis. MRI should be indicated in selected cases of oligohydramnios, fetal hydrops, fetal hepatomegaly, ascites, or unexplained FGR or anemia after ruling out all other more frequently encountered conditions. MRI can be used to detect iron overload in the liver and extrahepatic siderosis.
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Affiliation(s)
- Adelina Staicu
- 1st Department of Obstetrics and Gynecology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 1st Clinics of Obstetrics and Gynecology Cluj-Napoca, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
| | - Roxana Popa-Stanila
- Department of Radiology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- Centre of Advanced Research Studies, Emergency County Hospital, IMOGEN, 400006 Cluj-Napoca, Romania
| | - Camelia Albu
- Centre of Advanced Research Studies, Emergency County Hospital, IMOGEN, 400006 Cluj-Napoca, Romania
- Department of Pathology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Alexandra Chira
- Department of Internal Medicine, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 2nd Medical Clinic, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
| | - Roxana Constantin
- 1st Clinics of Obstetrics and Gynecology Cluj-Napoca, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
| | - Dan Boitor-Borza
- 1st Department of Obstetrics and Gynecology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 1st Clinics of Obstetrics and Gynecology Cluj-Napoca, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
| | - Mihai Surcel
- 1st Department of Obstetrics and Gynecology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 1st Clinics of Obstetrics and Gynecology Cluj-Napoca, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
| | - Ioana Cristina Rotar
- 1st Department of Obstetrics and Gynecology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 1st Clinics of Obstetrics and Gynecology Cluj-Napoca, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
| | - Gheorghe Cruciat
- 1st Department of Obstetrics and Gynecology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 1st Clinics of Obstetrics and Gynecology Cluj-Napoca, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
| | - Daniel Muresan
- 1st Department of Obstetrics and Gynecology, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 1st Clinics of Obstetrics and Gynecology Cluj-Napoca, Emergency County Clinical Hospital, 400006 Cluj-Napoca, Romania
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Mulzer LM, Reutter H, Jüngert J, Knisely AS, Schmid M, Hoerning A, Morhart P. Premature birth associated with a favorable course in gestational alloimmune liver disease (GALD): A case report. Front Pediatr 2023; 11:1104530. [PMID: 37009281 PMCID: PMC10054034 DOI: 10.3389/fped.2023.1104530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/20/2023] [Indexed: 04/04/2023] Open
Abstract
Gestational alloimmune liver disease (GALD) is a rare neonatal disorder with high mortality and morbidity. The patients come to caregivers' attention aged a few hours or days. The disease manifests as acute liver failure with or without siderosis. The differential diagnosis of neonatal acute liver failure (NALF) is broad, including mainly immunologic, infectious, metabolic and toxic disorders. The most common cause, however, is GALD followed by herpes simplex virus (HSV) infection. The best suited pathophysiological paradigm of GALD is that of a maternofetal alloimmune disorder. State of the art treatment combines intravenously administered immunoglobulin (IVIG) with exchange transfusion (ET). We report an infant born at 35 + 2 weeks' gestation in whom GALD had a favorable course, of interest because premature birth in our patient may have exerted protective aspects and lessened morbidity in that intrauterine exposure to maternal complement-fixing antibodies was shortened. The diagnosis of GALD was challenging and difficult. We suggest a modified diagnostic algorithm combining clinical findings with histopathologic findings in liver and lip mucosa and, if available, on abdominal magnetic resonance imaging-study focusing on the liver, spleen, and pancreas. This diagnostic workup must be followed by ET and subsequent administration of IVIG without delay.
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Affiliation(s)
- Linda-Marie Mulzer
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
- Correspondence: Linda-Marie Mulzer
| | - Heiko Reutter
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Jörg Jüngert
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
| | - A. S. Knisely
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Margit Schmid
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
| | - André Hoerning
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), ZSEER, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg, Erlangen, Germany
| | - Patrick Morhart
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
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Blended nylon 6,6 and choline glycinate-ionic liquid for adsorptive nanofiber membrane on the removal of Fe(III) from synthetic wastewater. J Mol Liq 2022. [DOI: 10.1016/j.molliq.2022.120677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Tsuge M, Kodera A, Sumitomo H, Araki T, Yoshida R, Yasui K, Sato H, Washio Y, Washio K, Shigehara K, Yashiro M, Yagi T, Tsukahara H. Neonatal hemochromatosis with εγδβ-thalassemia: a case report and analysis of serum iron regulators. BMC Pediatr 2022; 22:622. [PMID: 36309641 PMCID: PMC9617355 DOI: 10.1186/s12887-022-03706-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 10/24/2022] [Indexed: 12/05/2022] Open
Abstract
Background Neonatal hemochromatosis causes acute liver failure during the neonatal period, mostly due to gestational alloimmune liver disease (GALD). Thalassemia causes hemolytic anemia and ineffective erythropoiesis due to mutations in the globin gene. Although neonatal hemochromatosis and thalassemia have completely different causes, the coexistence of these diseases can synergistically exacerbate iron overload. We report that a newborn with εγδβ-thalassemia developed neonatal hemochromatosis, which did not respond to iron chelators and rapidly worsened, requiring living-donor liver transplantation. Case presentation A 1-day-old Japanese boy with hemolytic anemia and targeted red blood cells was diagnosed with εγδβ-thalassemia by genetic testing, and required frequent red blood cell transfusions. At 2 months after birth, exacerbation of jaundice, grayish-white stool, and high serum ferritin levels were observed, and liver biopsy showed iron deposition in hepatocytes and Kupffer cells. Magnetic resonance imaging scans showed findings suggestive of iron deposits in the liver, spleen, pancreas, and bone marrow. The total amount of red blood cell transfusions administered did not meet the criteria for post-transfusion iron overload. Administration of an iron-chelating agent was initiated, but iron overload rapidly progressed to liver failure without improvement in jaundice and liver damage. He underwent living-donor liver transplantation from his mother, after which iron overload disappeared, and no recurrence of iron overload was observed. Immunohistochemical staining for C5b-9 in the liver was positive. Serum hepcidin levels were low and serum growth differentiation factor-15 levels were high prior to living-donor liver transplantation. Conclusions We reported that an infant with εγδβ-thalassemia developed NH due to GALD, and that coexistence of ineffective erythropoiesis in addition to erythrocyte transfusions may have exacerbated iron overload. Low serum hepcidin levels, in this case, might have been caused by decreased hepcidin production arising from fetal liver damage due to neonatal hemochromatosis and increased hepcidin-inhibiting hematopoietic mediators due to the ineffective hematopoiesis observed in thalassemia. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03706-3.
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Last E, Ketteridge D, Moore D. Expanding the spectrum of gestational alloimmune liver disease. J Paediatr Child Health 2022; 58:1450-1451. [PMID: 34755414 DOI: 10.1111/jpc.15828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Eleanor Last
- Trainee Medical Officer Unit, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - David Ketteridge
- Metabolic Unit, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - David Moore
- Department of Gastroenterology, Women's and Children's Hospital, Adelaide, South Australia, Australia
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Hepatic manifestations of systemic disease: an imaging-based review. Pediatr Radiol 2022; 52:852-864. [PMID: 34797394 DOI: 10.1007/s00247-021-05222-5] [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: 06/20/2021] [Revised: 08/28/2021] [Accepted: 10/05/2021] [Indexed: 10/19/2022]
Abstract
The liver is responsible for many processes that maintain human metabolic homeostasis and can be affected by several pediatric systemic diseases. In this manuscript, we explore key pathological findings and imaging features across multiple modalities of a spectrum of congenital, metabolic and autoimmune disorders. Strengthening the radiologists' knowledge regarding potential hepatic manifestations of these systemic diseases will ultimately lead to improved care for pediatric patients.
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Foong CY, Darsiny D, Wirzal MDH, Abd Halim NS, Saad MS. Electrospun nanofiber adsorption amino-based ionic liquid for iron removal. INTERNATIONAL CONFERENCE ON TRENDS IN CHEMICAL ENGINEERING 2021 (ICOTRICE2021) 2022. [DOI: 10.1063/5.0114424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Oh KS, Bahmad HF, Brathwaite C, Sanchez AC, Recine M. Neonatal acute liver failure with pulmonary yellow hyaline membrane and kernicterus. AUTOPSY AND CASE REPORTS 2021; 11:e2021268. [PMID: 34307225 PMCID: PMC8214891 DOI: 10.4322/acr.2021.268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/19/2021] [Indexed: 12/01/2022] Open
Abstract
Background Neonatal acute liver failure (NALF) is a rare and life-threatening condition. It causes bilirubin to accumulate to a dangerous level in the body, causing permanent damage to vital organs such as the brain and lungs. In many cases, the etiology of NALF remains unknown. Case presentation We described a case of an 8-day-old baby girl who presented with poor oral intake, lethargy, and jaundice. Her clinical condition rapidly deteriorated with progression to multi-organ failure, and despite intensive resuscitation efforts, she expired. At autopsy, the most significant findings were liver necrosis, yellow hyaline membrane deposition in the lungs, and bilirubin deposition in the brain (kernicterus). Conclusions NALF is a rare and potentially fatal condition necessitating prompt recognition and disease-specific treatment approaches. Toxic accumulation of bilirubin in the lungs can lead to hypoxia and precipitate further ischemic injury to the liver.
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Affiliation(s)
- Kei Shing Oh
- Mount Sinai Medical Center, Arkadi M. Rywlin M.D. Department of Pathology and Laboratory Medicine, Miami, FL, USA
| | - Hisham F Bahmad
- Mount Sinai Medical Center, Arkadi M. Rywlin M.D. Department of Pathology and Laboratory Medicine, Miami, FL, USA
| | | | - Amilcar Castellano Sanchez
- Mount Sinai Medical Center, Arkadi M. Rywlin M.D. Department of Pathology and Laboratory Medicine, Miami, FL, USA.,Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Monica Recine
- Mount Sinai Medical Center, Arkadi M. Rywlin M.D. Department of Pathology and Laboratory Medicine, Miami, FL, USA
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Etiology of acute liver failure in children. PEDIATRU.RO 2021. [DOI: 10.26416/pedi.63.3.2021.5483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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10
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Ciobanu AM, Dumitru AE, Gica N, Botezatu R, Peltecu G, Panaitescu AM. Benefits and Risks of IgG Transplacental Transfer. Diagnostics (Basel) 2020; 10:E583. [PMID: 32806663 PMCID: PMC7459488 DOI: 10.3390/diagnostics10080583] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/13/2022] Open
Abstract
Maternal passage of immunoglobulin G (IgG) is an important passive mechanism for protecting the infant while the neonatal immune system is still immature and ineffective. IgG is the only antibody class capable of crossing the histological layers of the placenta by attaching to the neonatal Fc receptor expressed at the level of syncytiotrophoblasts, and it offers protection against neonatal infectious pathogens. In pregnant women with autoimmune or alloimmune disorders, or in those requiring certain types of biological therapy, transplacental passage of abnormal antibodies may cause fetal or neonatal harm. In this review, we will discuss the physiological mechanisms and benefits of transplacental transfer of maternal antibodies as well as pathological maternal situations where this system is hijacked, potentially leading to adverse neonatal outcomes.
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Affiliation(s)
- Anca Marina Ciobanu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | | | - Nicolae Gica
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | - Radu Botezatu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | - Gheorghe Peltecu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | - Anca Maria Panaitescu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
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Abstract
Neonatal acute liver failure (NALF) is a rare disease with a few known primary causes: gestational alloimmune liver disease (GALD), viral infections, metabolic diseases, and ischemic injury. Many cases still do not have a known cause. Laboratory evaluation may suggest a diagnosis. Most of the known causes have disease-specific treatments that improve outcomes. Survival is improving with better knowledge about and treatment options for GALD; however, overall mortality for NALF is still 24%. Liver transplant remains an important option for neonates with an indeterminate cause of NALF and those who do not respond to established treatments.
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Affiliation(s)
- Catherine Larson-Nath
- Pediatric Gastroenterology, Hepatology & Nutrition, University of Minnesota, 2450 Riverside Avenue, Minneapolis, MN 55454, USA
| | - Bernadette E Vitola
- Pediatric Gastroenterology, Hepatology & Nutrition, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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Yamada N, Inui A, Sanada Y, Ihara Y, Urahashi T, Fukuda A, Sakamoto S, Kasahara M, Yoshizawa A, Okamoto S, Okajima H, Fujisawa T, Mizuta K. Pediatric liver transplantation for neonatal-onset Niemann-Pick disease type C: Japanese multicenter experience. Pediatr Transplant 2019; 23:e13462. [PMID: 31081242 DOI: 10.1111/petr.13462] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 03/03/2019] [Accepted: 04/15/2019] [Indexed: 12/30/2022]
Abstract
Niemann-Pick disease type C (NPC) is a rare autosomal recessive inherited disease characterized by lysosomal accumulation of free cholesterol in macrophages within multiple organs. Infantile-onset NPC often presents with jaundice and hepatosplenomegaly from birth, but these symptoms usually improve during early childhood, and it rarely progresses to liver failure. We report three cases from different hospitals in Japan; the patients developed neonatal-onset NPC, and liver transplantation (LT) was performed as a life-saving procedure. LT was performed at 19 days, 59 days, and 4 months of age, respectively. The last patient was diagnosed with NPC before LT, while the first two patients were diagnosed with neonatal hemochromatosis at LT. In these two patients, the diagnosis of NPC was made more than a year after LT. Even though oral administration of miglustat was started soon after the diagnosis of NPC, all patients showed neurological regression and required artificial respiratory support. All patients survived more than one year after LT; however, one patient died due to tracheal hemorrhage at 4.5 years of age, and another one patient was suspected as recurrence of NPC in liver graft. In conclusion, while LT may be a temporary life-saving measure in patients with neonatal-onset NPC leading to liver failure, the outcome is poor especially due to neurological symptoms. A preoperative diagnosis is thus critical.
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Affiliation(s)
- Naoya Yamada
- Department of Transplant Surgery, Jichi Medical University, Tochigi, Japan
| | - Ayano Inui
- Department of Pediatric Hepatology and Gastroenterology, Eastern Yokohama Hospital, Kanagawa, Japan
| | - Yukihiro Sanada
- Department of Transplant Surgery, Jichi Medical University, Tochigi, Japan
| | - Yoshiyuki Ihara
- Department of Transplant Surgery, Jichi Medical University, Tochigi, Japan
| | - Taizen Urahashi
- Department of Transplant Surgery, Jichi Medical University, Tochigi, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Atsushi Yoshizawa
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinya Okamoto
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomoo Fujisawa
- Department of Pediatric Hepatology and Gastroenterology, Eastern Yokohama Hospital, Kanagawa, Japan
| | - Koichi Mizuta
- Department of Transplant Surgery, Jichi Medical University, Tochigi, Japan
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Wu H, Ferguson W, Castro E, Kearney D, Finegold M, Patel K. Extrahepatic Nonreticuloendothelial Siderosis Is Not Specific to Gestational Alloimmune Liver Disease. Pediatr Dev Pathol 2019; 22:356-364. [PMID: 30722724 DOI: 10.1177/1093526619826429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Autopsy reports of 78 stillbirths and early infant deaths (up to age 8 weeks) were reviewed to investigate the prevalence of extrahepatic nonreticuloendothelial siderosis (EHNRS) in the context of neonatal liver failure. Of these, 10 liveborns (12.8%), M:F 3:2, with mean gestational age 37.6 weeks (range: 35-39) and mean age at the time of demise 19.1 days (range: 7-42), showed significant liver injury: infection (n = 7, viral > fungal), congenital malformations (n = 2), and ischemia (n = 1). None had maternal history of gestational alloimmune liver disease (GALD) or previous fetal/neonatal death due to liver failure. Seven of 10 cases (70%) showed EHNRS: pancreas (n = 6), kidneys (n = 4), thyroid and adrenal glands (n = 3), and bronchial glands and heart (n = 2). Iron deposition was most frequent in the pancreas (60%), most diffuse in the kidneys, and seen in at least 2 organs, with pancreas and kidney being the most frequent combination. Hepatic C5b-9 expression was variable (1+ to 4+) except 1 case (100% necrosis). The duration of illness and the mean age at the time of demise tended to be higher in those with EHNRS. In summary, hepatic and EHNRS, with or without C5b-9 expression, are not specific for GALD. Other causes of liver failure should be investigated as clinically and pathologically appropriate.
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Affiliation(s)
- Hao Wu
- 1 Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - William Ferguson
- 1 Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Eumenia Castro
- 1 Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Debra Kearney
- 1 Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Milton Finegold
- 1 Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Kalyani Patel
- 1 Department of Pathology, Texas Children's Hospital, Houston, Texas
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Kasko O, Klose E, Rama G, Newberry D, Jnah A. Gestational Alloimmune Liver Disease: A Case Study. Neonatal Netw 2019; 37:271-280. [PMID: 30567809 DOI: 10.1891/0730-0832.37.5.271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Gestational alloimmune liver disease (GALD) is initiated by maternal antibodies that attack fetal hepatocytes. The fetal immune response to the antibodies causes liver damage. The incidence of GALD is four per 100,000 live births in the United States. Frequently, liver injury leads to fetal loss or neonatal demise; nonetheless, the presentation of GALD has a wide range of severity. Survival rates have increased from 20 to 80 percent changes in treatment and understanding of GALD. Current treatment is focused on supportive care with intravenous immunoglobulin (IVIG) and exchange transfusions. Mortality risk is positively associated with the timing of diagnosis. Although there has been an increase in understanding this disease, the discovery of the specific alloantigen is still needed. Relevant embryology, pathophysiology, clinical manifestations, diagnosis, medical treatment, and prognosis are discussed to aid health care professionals in the early identification and treatment for the neonate and family unit.
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Abstract
Most cells in the body acquire iron via receptor-mediated endocytosis of transferrin, the circulating iron transport protein. When cellular iron levels are sufficient, the uptake of transferrin decreases to limit further iron assimilation and prevent excessive iron accumulation. In iron overload conditions, such as hereditary hemochromatosis and thalassemia major, unregulated iron entry into the plasma overwhelms the carrying capacity of transferrin, resulting in non-transferrin-bound iron (NTBI), a redox-active, potentially toxic form of iron. Plasma NTBI is rapidly cleared from the circulation primarily by the liver and other organs (e.g., pancreas, heart, and pituitary) where it contributes significantly to tissue iron overload and related pathology. While NTBI is usually not detectable in the plasma of healthy individuals, it does appear to be a normal constituent of brain interstitial fluid and therefore likely serves as an important source of iron for most cell types in the CNS. A growing body of literature indicates that NTBI uptake is mediated by non-transferrin-bound iron transporters such as ZIP14, L-type and T-type calcium channels, DMT1, ZIP8, and TRPC6. This review provides an overview of NTBI uptake by various tissues and cells and summarizes the evidence for and against the roles of individual transporters in this process.
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Affiliation(s)
- Mitchell D Knutson
- Food Science and Human Nutrition Department, University of Florida, Gainesville, FL, USA.
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Darouich S, Boujelbène N, Amraoui J, Amraoui N, Masmoudi A. Hemochromatosis associated with cholelithiasis as a cause of hydrops fetalis and stillbirth: Prenatal diagnosis. JOURNAL OF CLINICAL ULTRASOUND : JCU 2019; 47:47-50. [PMID: 30378124 DOI: 10.1002/jcu.22653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 09/15/2018] [Accepted: 09/24/2018] [Indexed: 06/08/2023]
Abstract
Prenatal diagnosis of neonatal hemochromatosis (NH) is usually raised in front of fetal hepatomegaly and heterogeneous liver architecture. We describe a novel sonographic feature that may be associated with NH. Ultrasound demonstrated reticulonodular liver and distended gallbladder with multiple gallstones in a hydropic fetus. These abnormalities were confirmed to be consistent with NH after correlation with autopsy findings. This case report highlights the value of cholelithiasis in clinical suspicion of NH and the importance to consider this sonographic feature when the liver has abnormal texture.
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Affiliation(s)
- Sihem Darouich
- Fetopathology Unit, Hospital Habib Bougatfa, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Nadia Boujelbène
- Department of Pathology, Salah Azaiez Institute, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Jihen Amraoui
- Department of Obstetrics and Gynecology, Centre de Hospitalier de Sens, Sens, France
| | | | - Aida Masmoudi
- Department of Embryo-Fetopathology, Maternity and Neonatology Center, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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17
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Narkewicz MR, Horslen S, Hardison RM, Shneider BL, Rodriguez-Baez N, Alonso EM, Ng VL, Leonis MA, Loomes KM, Rudnick DA, Rosenthal P, Romero R, Subbarao GC, Li R, Belle SH, Squires RH. A Learning Collaborative Approach Increases Specificity of Diagnosis of Acute Liver Failure in Pediatric Patients. Clin Gastroenterol Hepatol 2018; 16:1801-1810.e3. [PMID: 29723692 PMCID: PMC6197895 DOI: 10.1016/j.cgh.2018.04.050] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/11/2018] [Accepted: 04/20/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Many pediatric patients with acute liver failure (PALF) do not receive a specific diagnosis (such as herpes simplex virus or Wilson disease or fatty acid oxidation defects)-they are left with an indeterminate diagnosis and are more likely to undergo liver transplantation, which is contraindicated for some disorders. Strategies to facilitate complete diagnostic testing should increase identification of specific liver diseases and might reduce liver transplantation. We investigated whether performing recommended age-specific diagnostic tests (AS-DTs) at the time of hospital admission reduces the percentage PALFs with an indeterminate diagnosis. METHODS We performed a multinational observational cohort study of 658 PALF participants in the United States and Canada, enrolled at 10 medical centers, during 3 study phases from December 1999 through December 2014. A learning collaborative approach was used to implement AS-DT using an electronic medical record admission order set at hospital admission in phase 3 of the study. Data from 10 study sites participating in all 3 phases were compared before (phases 1 and 2) and after (phase 3) diagnostic test recommendations were inserted into electronic medical record order sets. RESULTS The percentage of subjects with an indeterminate diagnosis decreased significantly between phases 1-2 (48.0%) and phase 3 (to 30.8%) (P = .0003). The 21-day cumulative incidence rates for liver transplantation were significantly different among phase 1 (34.6%), phase 2 (31.9%), and phase 3 (20.2%) (P = .030). The 21-day cumulative incidence rates for death did not differ significantly among phase 1 (17.9%), phase 2 (11.9%), and phase 3 (11.3%) (P = .20). CONCLUSIONS In a multinational study of children with acute liver failure, we found that incorporating diagnostic test recommendations into electronic medical record order sets accessed at time of admission reduced the percentage with an indeterminate diagnosis that may have reduced liver transplants without increasing mortality. Widespread use of this approach could significantly enhance care of acute liver failure in children.
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Affiliation(s)
- Michael R Narkewicz
- Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Simon Horslen
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital and Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Regina M Hardison
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Benjamin L Shneider
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Norberto Rodriguez-Baez
- Department of Pediatrics, Division of Gastroenterology, University of Texas Southwestern, Dallas, Texas
| | - Estella M Alonso
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago Illinois
| | - Vicky L Ng
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Mike A Leonis
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Alabama Birmingham, Birmingham, Alabama
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David A Rudnick
- Department of Pediatrics, Department of Developmental Biology, Washington University School of Medicine, St. Louis, Missouri
| | - Philip Rosenthal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, UCSF Benioff Children's Hospital, Department of Pediatrics and Surgery, University of California, San Francisco, San Francisco, California
| | - Rene Romero
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Girish C Subbarao
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Indiana School of Medicine and Riley Children's Hospital, Indianapolis, Indiana
| | - Ruosha Li
- Department of Biostatistics and Data Science, the University of Texas Health Science Center at Houston, Houston, Texas
| | - Steven H Belle
- Department of Epidemiology, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Robert H Squires
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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18
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Bastos KLDM, Quaio CR, Lima FR, Araújo IM, Araújo CAT, Piazzon FB, Silva IDCGD, Benevides GN, Tannuri AC, Tannuri U, Azevedo RA, Kim CA. Biochemical profile in an infant with neonatal hemochromatosis shows evidence of impairment of mitochondrial long-chain fatty acid oxidation. Clin Mol Hepatol 2018; 25:86-91. [PMID: 30149691 PMCID: PMC6435974 DOI: 10.3350/cmh.2018.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 06/08/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Caio Robledo Quaio
- Children's Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.,Fleury Group, Sao Paulo, Brazil
| | - Fabiana Roberto Lima
- Department of Pathology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Iana Manuelle Araújo
- Children's Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | | | - Flávia Balbo Piazzon
- Children's Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.,APAE, Sao Paulo, Brazil
| | | | | | - Ana Cristina Tannuri
- Children's Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Uenis Tannuri
- Children's Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Ramiro Anthero Azevedo
- Children's Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.,Sao Paulo Federal University, Sao Paulo, Brazil
| | - Chong Ae Kim
- Children's Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
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19
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Taylor SA, Kelly S, Alonso EM, Whitington PF. The Effects of Gestational Alloimmune Liver Disease on Fetal and Infant Morbidity and Mortality. J Pediatr 2018; 196:123-128.e1. [PMID: 29499991 DOI: 10.1016/j.jpeds.2017.12.054] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 12/14/2017] [Accepted: 12/19/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To evaluate pregnancy outcomes in pedigrees of neonatal hemochromatosis to determine the spectrum of gestational alloimmune liver disease (GALD) in a large cohort. STUDY DESIGN We prospectively collected data from women with a prior offspring with proven neonatal hemochromatosis between 1997 and 2015 and analyzed pregnancy outcomes. RESULTS The pedigrees from 150 women included 350 gestations with outcomes potentially related to GALD. There were 105 live-born infants without liver disease, 157 live-born infants with liver failure, and 88 fetal losses. Fetal loss occurred in 25% of total gestations. Ninety-seven pedigrees contained a single affected offspring, whereas 53 contained multiple affected offspring. Analysis of these 53 pedigrees yielded a per-pregnancy repeat occurrence rate of 95%. Notably, the first poor outcome occurred in the first pregnancy in 60% of pedigrees. Outcomes of the 157 live-born infants with liver failure were poor: 18% survived, 82% died. Of the 134 live-born infants with treatment data, 20 received intravenous immunoglobulin with or without double-volume exchange transfusion of which 9 (45%) survived; 14 infants (10%) received a liver transplant of which 6 (43%) survived. CONCLUSIONS GALD is a significant cause of both fetal loss and neonatal mortality with a high rate of disease recurrence in untreated pregnancies at risk. Poor outcomes related to GALD commonly occur in the first gestation, necessitating a high index of suspicion to diagnose this disorder at first presentation.
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Affiliation(s)
- Sarah A Taylor
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL.
| | - Susan Kelly
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL
| | - Estella M Alonso
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL
| | - Peter F Whitington
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL
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20
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Ross SL, Biswas K, Rottman J, Allen JR, Long J, Miranda LP, Winters A, Arvedson TL. Identification of Antibody and Small Molecule Antagonists of Ferroportin-Hepcidin Interaction. Front Pharmacol 2017; 8:838. [PMID: 29209212 PMCID: PMC5702341 DOI: 10.3389/fphar.2017.00838] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 11/03/2017] [Indexed: 12/21/2022] Open
Abstract
The iron exporter ferroportin and its ligand, the hormone hepcidin, control fluxes of stored and recycled iron for use in a variety of essential biochemical processes. Inflammatory disorders and malignancies are often associated with high hepcidin levels, leading to ferroportin down-regulation, iron sequestration in tissue macrophages and subsequent anemia. The objective of this research was to develop reagents to characterize the expression of ferroportin, the interaction between ferroportin and hepcidin, as well as to identify novel ferroportin antagonists capable of maintaining iron export in the presence of hepcidin. Development of investigative tools that enabled cell-based screening assays is described in detail, including specific and sensitive monoclonal antibodies that detect endogenously-expressed human and mouse ferroportin and fluorescently-labeled chemically-synthesized human hepcidin. Large and small molecule antagonists inhibiting hepcidin-mediated ferroportin internalization were identified, and unique insights into the requirements for interaction between these two key iron homeostasis molecules are provided.
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Affiliation(s)
- Sandra L Ross
- Department of Oncology Research, Amgen Inc., Thousand Oaks, CA, United States
| | - Kaustav Biswas
- Department of Hybrid Modality Engineering, Amgen Inc., Thousand Oaks, CA, United States
| | - James Rottman
- Department of Comparative Biology and Safety Sciences, Amgen Inc., Thousand Oaks, CA, United States
| | - Jennifer R Allen
- Department of Medicinal Chemistry, Amgen Inc., Thousand Oaks, CA, United States
| | - Jason Long
- Department of Hybrid Modality Engineering, Amgen Inc., Thousand Oaks, CA, United States
| | - Les P Miranda
- Department of Hybrid Modality Engineering, Amgen Inc., Thousand Oaks, CA, United States
| | - Aaron Winters
- Department of Therapeutic Discovery, Amgen Inc., Thousand Oaks, CA, United States
| | - Tara L Arvedson
- Department of Oncology Research, Amgen Inc., Thousand Oaks, CA, United States
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21
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Dubruc E, Nadaud B, Ruchelli E, Heissat S, Baruteau J, Broué P, Debray D, Cordier MP, Miossec P, Russo P, Collardeau-Frachon S. Relevance of C5b9 immunostaining in the diagnosis of neonatal hemochromatosis. Pediatr Res 2017; 81:712-721. [PMID: 28085791 DOI: 10.1038/pr.2017.8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 12/04/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Neonatal hemochromatosis caused by a gestational alloimmune mechanism or gestational alloimmune liver disease (GALD) is a rare perinatal disorder characterized by intra- and extrahepatic iron overload. It is believed to result from complement-mediated liver injury, in which the classical complement pathway is activated by maternal antibody/fetal antigen complexes, leading to hepatocyte lysis by the membrane attack complex C5b9. According to some authors, C5b9 expression in more than 75% of liver parenchyma is specific for GALD. METHODS We conducted a retrospective multicentric immunohistochemical study with anti-C5b9 in GALD cases (n = 25) and non-GALD cases with iron overload (n = 36) and without iron overload (n = 18). RESULTS C5b9 was expressed in 100% of GALD cases but involved more than 75% of the liver parenchyma in only 26% of the cases. C5b9 was detected in 26.75% of the non-GALD cases with more than 75% of positive parenchyma in maternal erythrocytic alloimmunization, herpes and enterovirus hepatitis, bile acid synthetic defect, DGUOK mutation, Gaucher disease, cystic fibrosis, and giant-cell hepatitis with autoimmune hemolytic anemia. CONCLUSION Diagnosis and therapeutic management of GALD cannot only be based on C5b9 expression in liver samples as it is not specific of this disease.
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Affiliation(s)
- Estelle Dubruc
- Department of pathology, Hôpital Femme-Mère-Enfant, CHU de Lyon, France
| | - Béatrice Nadaud
- Department of pathology, Hôpital Femme-Mère-Enfant, CHU de Lyon, France
| | - Eduardo Ruchelli
- Department of pathology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sophie Heissat
- Department of pediatrics, Hôpital Femme-Mère-Enfant, CHU de Lyon, France
| | - Julien Baruteau
- Pediatric Hepatology and Inborn Metabolic Diseases Unit, University Children's Hospital, Toulouse, France
| | - Pierre Broué
- Pediatric Hepatology and Inborn Metabolic Diseases Unit, University Children's Hospital, Toulouse, France
| | - Dominique Debray
- Department of Pediatric Surgery, Hepatology, and Transplantation, Necker Enfants Malades Hospital, Paris, France
| | | | - Pierre Miossec
- Department of immunology, Hôpital Edouard Herriot, CHU de Lyon, France.,Université Claude Bernard Lyon 1, France
| | - Pierre Russo
- Department of pathology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sophie Collardeau-Frachon
- Department of pathology, Hôpital Femme-Mère-Enfant, CHU de Lyon, France.,Université Claude Bernard Lyon 1, France.,SOFFOET, Société Française de Foetopathologie, Paris, France
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22
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Taylor SA, Whitington PF. Neonatal acute liver failure. Liver Transpl 2016; 22:677-85. [PMID: 26946058 DOI: 10.1002/lt.24433] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 02/16/2016] [Accepted: 02/24/2016] [Indexed: 12/23/2022]
Abstract
Neonatal acute liver failure (NALF) is a rare disease about which there is little published data; however, NALF is an extremely important condition as it is distinct from acute liver failure seen in older children and adults. First, unlike acute liver failure in older patients, NALF can be diagnosed in an infant with cirrhosis. This is due to the fetal-neonatal continuum of liver disease, or the principle that neonatal liver failure may be the result of a liver disease that began in utero. Further differences exist in the mechanism of disease, diagnostic principles, and the common etiologies of NALF when compared with pediatric and adult acute liver failure. This review will address many of the distinguishing features of NALF and focus on the most common etiologies of NALF, including gestational alloimmune liver disease (GALD), the most common cause of NALF. Additionally, this review will provide insight into the pathogenesis, diagnosis, and treatment of this rare condition. Liver Transplantation 22 677-685 2016 AASLD.
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Affiliation(s)
- Sarah A Taylor
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Peter F Whitington
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL
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23
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Hemocromatosis neonatal: otra entidad que deja de ser huérfana. Avances en el diagnóstico y manejo de la principal causa de fallo hepático agudo neonatal. An Pediatr (Barc) 2015; 83:218.e1-3. [DOI: 10.1016/j.anpedi.2015.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 02/09/2015] [Indexed: 11/17/2022] Open
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24
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Molera Busoms C, Quintero Bernabeu J, Martín de Carpi J. Neonatal hemochromatosis: Another entity that is no longer orphan. Advances in the diagnosis and management of the main cause of neonatal acute liver failure. An Pediatr (Barc) 2015. [DOI: 10.1016/j.anpede.2015.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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25
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Roumiantsev S, Shah U, Westra SJ, Misdraji J. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 20-2015. A Newborn Girl with Hypotension, Coagulopathy, Anemia, and Hyperbilirubinemia. N Engl J Med 2015; 372:2542-53. [PMID: 26107055 DOI: 10.1056/nejmcpc1404334] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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26
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Melin-Aldana H, Park C, Pan X, Fritsch M, Malladi P, Whitington P. Gestational autoimmune disease in newborns with an indeterminate cause of death following a complete autopsy. J Neonatal Perinatal Med 2015; 8:0530808451Q626G0. [PMID: 25766200 DOI: 10.3233/npm-15814060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Gestational alloimmune liver disease (GALD) is the result of neonatal complement-mediated severe liver injury mediated by maternal alloantibodies, which is detected by immunohistochemistry staining for the complement C5b-9 complex. GALD leads to the neonatal hemochromatosis (NH) phenotype, which also shows extrahepatic siderosis, and can result in neonatal death. At autopsy, the histologic damage of the liver in GALD may be subtle and misinterpreted as non-specific post-mortem changes, resulting in the cause of death classified as indeterminate. We reviewed the pathologic diagnoses from autopsy material from 1996 to 2011 of infants 0-90 days of age from our institution. Liver samples were stained with H&E, trichrome and for C5b-9. 13 cases originally diagnosed as indeterminate cause of death were identified and divided in 3 groups: (1) No clinical or autopsy-derived diagnoses (n = 7), (2) Defined clinical diagnoses but no cause of death determined at autopsy (n = 2), and (3) Liver disease, but no clinical or autopsy diagnoses to establish the cause of the liver injury (n = 4). On reexamination, all group 1 and 3 cases were reclassified as GALD, based on a positive C5b-9 stain. Group 2 cases were not GALD, retaining the original, clinically-based cause of death. We conclude that, in cases of indeterminate cause of neonatal death, very careful examination for hepatocyte injury/necrosis, extrahepatic siderosis, liver fibrosis and/or C5b-9 stain should be considered.
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Affiliation(s)
- H Melin-Aldana
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - C Park
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - X Pan
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - M Fritsch
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - P Malladi
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - P Whitington
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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27
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Heissat S, Collardeau-Frachon S, Baruteau J, Dubruc E, Bouvier R, Fabre M, Cordier MP, Broué P, Guigonis V, Debray D. Neonatal hemochromatosis: diagnostic work-up based on a series of 56 cases of fetal death and neonatal liver failure. J Pediatr 2015; 166:66-73. [PMID: 25444000 DOI: 10.1016/j.jpeds.2014.09.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 08/14/2014] [Accepted: 09/18/2014] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To define an algorithm to improve diagnosis of neonatal hemochromatosis (NH) related to gestational alloimmune liver disease (GALD), which is diagnosed by immunohistochemistry demonstrating activated complement at hepatocytes (IDACH). STUDY DESIGN We assessed 56 instances of fetal death or neonatal liver failure (NLF; 2006-2009), 29 (7 stillborns, 22 NLF) with NH, and 27 (5 stillborns, 22 NLF) without NH (non-NH). Immunohistochemistry was retrospectively performed in 21 cases. Cases were grouped as follows: (1) GALD as demonstrated by IDACH (n = 17); (2) indeterminate for GALD (n = 28); or (3) alternate diagnosis found (n = 11). We compared cases of immunohistochemically proven GALD with those with an alternate diagnosis. RESULTS Of the 12 stillborns, 7 had NH because of GALD (NH-GALD), one was undeterminate, and 4 had alternate diagnoses (GALD excluded). Of the 22 newborns with NH, 6 had NH-GALD, one had mitochondrial respiratory chain disorder (MRCD), and 15 were indeterminate for GALD. Of 22 non-NH newborns, extrahepatic siderosis (EHS) was not assessed in 13 (3 GALD, 1 alternate diagnosis [MRCD] and 9 indeterminate GALD) and excluded in 9 (5 alternate diagnoses and 4 indeterminate GALD). The only clinical features found to be associated with GALD were intrafamilial recurrence, prematurity, and EHS. CONCLUSIONS In unexplained fetal death or NLF, the diagnosis of subsets of NH requires tissue analysis (autopsy) to assess EHS. In patients with NH, if MRCD is ruled out, NH-GALD is likely. The rate of IDACH in the diagnosis of GALD in cases without NH requires further study.
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Affiliation(s)
- Sophie Heissat
- Department of Pediatric Gastroenterology and Hepatology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon et Université Lyon 1, Lyon, France.
| | - Sophie Collardeau-Frachon
- Department of Pathology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon et Université Lyon 1, Lyon, France
| | - Julien Baruteau
- Department of Pediatric Hepatology and Metabolic Diseases, CHU Toulouse, Toulouse, France
| | - Estelle Dubruc
- Department of Pathology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon et Université Lyon 1, Lyon, France
| | - Raymonde Bouvier
- Department of Pathology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon et Université Lyon 1, Lyon, France
| | | | | | - Pierre Broué
- Department of Pediatric Hepatology and Metabolic Diseases, CHU Toulouse, Toulouse, France
| | - Vincent Guigonis
- Department of Pediatrics, Hôpital Mère et Enfant, CHU Limoges, Limoges, France
| | - Dominique Debray
- Medical-Surgical Center, Hepatology, and Transplantation AP-HP, Hôpital Necker Enfants Malades, Paris, France
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28
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Elaboration of tubules with active hedgehog drives parenchymal fibrogenesis in gestational alloimmune liver disease. Hum Pathol 2015; 46:84-93. [DOI: 10.1016/j.humpath.2014.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/17/2014] [Accepted: 09/19/2014] [Indexed: 12/28/2022]
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Transient neonatal liver disease after maternal antenatal intravenous Ig infusions in gestational alloimmune liver disease associated with neonatal haemochromatosis. J Pediatr Gastroenterol Nutr 2014; 59:629-35. [PMID: 25079484 DOI: 10.1097/mpg.0000000000000514] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Neonatal haemochromatosis is a rare gestational disease that results in severe foetal liver disease with extrahepatic iron overload, sparing the reticuloendothelial system. Recurrence can be prevented with intravenous immunoglobulin (IVIG) infusions during pregnancy, supporting an alloimmune aetiology. The aim of the study was to assess the effect of antenatal treatment with IVIG infusion on the outcome of pregnancies in women with a history of documented neonatal haemochromatosis likely owing to gestational alloimmune disease and to analyse IVIG tolerance. METHODS From 2004 to 2012, 8 pregnant women were treated with IVIG at 1 g/kg body weight weekly from 18 weeks' gestation until birth in a prospective multicentre study. RESULTS All 8 neonates born to the treated women survived. Five developed mild neonatal liver disease with hepatomegaly (n = 1), hyperechogenic liver (n = 2), abnormal liver function tests (n = 1), raised serum ferritin (n = 3) and α-fetoprotein (n = 5) levels, or mild iron overload on liver magnetic resonance imaging (n = 1). Ferritin and α-fetoprotein levels normalised before 14 days and 2 months, respectively. A per-mother-basis analysis comparing outcomes of treated (n = 8) and untreated (n = 9) gestations showed a significant improvement in the survival of neonates with gestational IVIG therapy (survival 8/8 vs 0/9, P < 0.001). Adverse effects of IVIG infusion occurred in 5 mothers leading to discontinuation of treatment in 1 case. Preterm neonates born before 37 weeks' gestation had a decreased risk of neonatal liver disease (P = 0.04). CONCLUSIONS Antenatal treatment with IVIG infusion in women at risk for gestational alloimmune disease recurrence improves the outcome of pregnancies despite mild signs of transient neonatal liver disease.
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30
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Agrawal S, Dhiman RK. Hepatobiliary quiz-9 (2014). J Clin Exp Hepatol 2014; 4:81-4. [PMID: 25755542 PMCID: PMC4188737 DOI: 10.1016/j.jceh.2014.03.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Radha K. Dhiman
- Address for correspondence: Radha K. Dhiman, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Abstract
Neonatal hemochromatosis is a clinical condition in which severe liver disease in the newborn is accompanied by extrahepatic siderosis. Gestational alloimmune liver disease (GALD) has been established as the cause of fetal liver injury resulting in nearly all cases of NH. In GALD, a women is exposed to a fetal antigen that she does not recognize as "self" and subsequently begins to produce IgG antibodies that are directed against fetal hepatocytes. These antibodies bind to fetal liver antigen and activate the terminal complement cascade resulting in hepatocyte injury and death. GALD can cause congenital cirrhosis or acute liver failure with and without iron overload and siderosis. Practitioners should consider GALD in cases of fetal demise, stillbirth, and neonatal acute liver failure. Identification of infants with GALD is important as treatment is available and effective for subsequent pregnancies.
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Affiliation(s)
- Amy G. Feldman
- Address for correspondence. Amy G. Feldman, MD, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 57, Chicago, IL 60611-2605, United States. Tel.: +1 312 227 7600; fax: +1 312 227 9645.
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Primary biliary cirrhosis-specific antimitochondrial antibodies in neonatal haemochromatosis. Clin Dev Immunol 2013; 2013:642643. [PMID: 24171034 PMCID: PMC3792542 DOI: 10.1155/2013/642643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 08/22/2013] [Indexed: 01/14/2023]
Abstract
Background and Aim. Neonatal hemochromatosis (NH) is characterised by severe liver injury and extrahepatic siderosis sparing the reticuloendothelial system. Its aetiology is obscure, although it has been proposed as an alloimmune disease, resulting from immunological reaction to self-antigens (alloantigens) which the body recognizes as foreign. We studied an infant with NH and his mother whose sera contained antimitochondrial antibody (AMA), the hallmark of primary biliary cirrhosis (PBC). Material and Methods. To investigate the origin of AMA in the infant, we studied isotype distributions in serum from the mother and infant. Serum samples were obtained at diagnosis of NH, after liver transplantation (LT; age 1 month), and over the ensuing 17 months. Results. At NH diagnosis, infant and maternal serum contained AMA of the IgG isotype, predominantly of the G3 and G1 subclasses. AMA strongly reacted against the pyruvate dehydrogenase complex E2 subunit (PDC-E2), the major PBC-specific AMA autoantigen. Anti-PDC-E2 responses in both infant and mother declined over time, being present 2 months after LT (mother and child) and absent 10 months later (mother) and 17 months later (child). Conclusion. The association of maternally transferred IgG1 and IgG3 subclass AMA with the appearance of liver damage in an infant with NH may suggest a causal link between antibody and liver damage.
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Lopriore E, Mearin ML, Oepkes D, Devlieger R, Whitington PF. Neonatal hemochromatosis: management, outcome, and prevention. Prenat Diagn 2013; 33:1221-5. [PMID: 24030714 DOI: 10.1002/pd.4232] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 08/30/2013] [Accepted: 08/31/2013] [Indexed: 12/25/2022]
Abstract
Neonatal hemochromatosis (NH) is a rare disorder but the most common cause of acute liver failure in neonates. NH is characterized by severe hepatic injury and iron overload and is associated with high perinatal mortality and morbidity rates. NH is often preceded by oligohydramnios and intrauterine growth restriction, suggesting an important impact of NH during fetal life. Stillbirth and prematurity are not uncommon. During the last decade, major discoveries on the etiology of NH have radically changed the management and outcome of this disease. NH is now regarded as an alloimmune disease and is, as such, often referred to as gestational alloimmune liver disease. Antenatal treatment with intravenous immunoglobulins starting at 14 weeks' gestation has been shown to prevent the development of NH in subsequent pregnancies. Postnatal treatment, previously based on the use of anti-oxidants and chelation therapy, has now successfully been replaced by exchange transfusions and intravenous immunoglobulins substitution. This review summarizes the latest discoveries on the etiology of NH and the new recommendations concerning its management and prevention.
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Affiliation(s)
- Enrico Lopriore
- Division of Neonatology and Gastroenterology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Collardeau-Frachon S, Heissat S, Bouvier R, Fabre M, Baruteau J, Broue P, Cordier MP, Debray D, Debiec H, Ronco P, Guigonis V. French retrospective multicentric study of neonatal hemochromatosis: importance of autopsy and autoimmune maternal manifestations. Pediatr Dev Pathol 2012; 15:450-70. [PMID: 22901025 DOI: 10.2350/12-02-1155-oa.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Neonatal hemochromatosis is a rare disease that causes fetal loss and neonatal death in the 1st weeks of life and is one of the most common causes of liver failure in the neonate. The diagnosis is mostly made retrospectively, based on histopathologic features of severe liver fibrosis associated with hepatic and extrahepatic siderosis. Several etiologies may underlie this phenotype, including a recently hypothesized gestational alloimmune disease. Fifty-one cases of liver failure with intrahepatic siderosis in fetuses and neonates were analyzed retrospectively. Maternal and infant data were collected from hospitalization and autopsy reports. All available slides were reviewed independently by 3 pathologists. Immunologic studies were performed on maternal sera collected immediately after delivery. The diagnosis of neonatal haemochromatosis was retained in 33 cases, including 1 case with Down syndrome and 1 case with myofibromas. Liver siderosis was inversely proportional to fibrosis progression. In fetuses, iron storage was more frequent in the thyroid than in the pancreas. Perls staining in labial salivary glands was positive in 1 of 5 cases. Abnormal low signal intensity by magnetic resonance imaging was detected in the pancreas in 2 of 7 cases. Renal tubular dysgenesis was observed in 7 of 23 autopsy cases. Chronic villitis was seen in 7 of 15 placentas. Half of the mothers presented with an autoimmune background and/or autoantibodies in their sera. Our work highlights the importance of autopsy in cases of neonatal hemochromatosis and marshals additional data in support of the hypothesis that neonatal hemochromatosis could reflect maternal immune system dysregulation.
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Zoller H, Knisely AS. Control of iron metabolism--lessons from neonatal hemochromatosis. J Hepatol 2012; 56:1226-9. [PMID: 22402293 DOI: 10.1016/j.jhep.2012.02.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 02/24/2012] [Indexed: 01/16/2023]
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