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Ajmera A, Pernicone PJ, Patel N, Benabe SH. Coronavirus HKU1 infection and development of pediatric acute liver failure with immune dysregulation phenotype. JPGN REPORTS 2024; 5:204-207. [PMID: 38756108 PMCID: PMC11093931 DOI: 10.1002/jpr3.12065] [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: 06/12/2023] [Revised: 01/23/2024] [Accepted: 02/18/2024] [Indexed: 05/18/2024]
Abstract
Pediatric acute liver failure is a rare but serious complication of Coronavirus infections. Our patient is a previously healthy 8-year-old male who presented with acute liver failure in the setting of human coronavirus HKU1 (HCoV-HKU1) infection while asymptomatic from a respiratory perspective. During the hospital course, he developed acute hepatic encephalopathy and was listed for liver transplantation, but fortunately recovered remaining status 7 (inactive) on the transplant list. With a negative diagnostic evaluation other than his viral infection and hyperdense CD8 T-cells on liver immunohistochemical staining, pediatric acute liver failure (PALF) immune dysregulation phenotype was diagnosed.
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Affiliation(s)
- Arun Ajmera
- Center for Digestive Health and NutritionArnold Palmer Hospital for ChildrenOrlandoFloridaUSA
| | | | - Nishant Patel
- Center for Digestive Health and NutritionArnold Palmer Hospital for ChildrenOrlandoFloridaUSA
| | - Stefany Hernandez Benabe
- Advent Health Medical Group Pediatric Gastroenterology at OrlandoAdvent Health for ChildrenOrlandoFloridaUSA
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2
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Gutierrez Sanchez LH, Ibrahim SH. Severe Acute Hepatitis of Unknown Etiology in Children: New Virus or Immune Dysregulation. Gastroenterology 2024:S0016-5085(24)00481-5. [PMID: 38663818 DOI: 10.1053/j.gastro.2024.04.016] [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: 02/05/2024] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 06/02/2024]
Affiliation(s)
- Luz Helena Gutierrez Sanchez
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Samar H Ibrahim
- Division of Gastroenterology and Hepatology, Division of Pediatric Gastroenterology, Mayo Clinic, Rochester, Minnesota
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3
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Diamond T, Lau M, Morrissette J, Chu N, Behrens EM. CXCL9 inhibition does not ameliorate disease in murine models of both primary and secondary hemophagocytic lymphohistiocytosis. Sci Rep 2023; 13:12298. [PMID: 37516815 PMCID: PMC10387083 DOI: 10.1038/s41598-023-39601-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/27/2023] [Indexed: 07/31/2023] Open
Abstract
Hemophagocytic Lymphohistiocytosis (HLH) is a group of disorders culminating in systemic inflammation and multi-organ failure with high incidence of hepatic dysfunction. Overproduction of IFN-γ is the main immunopathological driver in this disorder. Monokine induced by IFN-γ (CXCL9) serves as a biomarker for disease activity and response to treatment in this disorder. However, very little is understood about the actual functional role of CXCL9 in pathogenesis in HLH. In the current study, we sought to determine the role of CXCL9 in pathogenesis in murine models of both Familial HLH (prf1-/-) and Toll Like Receptor (TLR) 9 repeated stimulation induced Macrophage Activation Syndrome (MAS), a form of secondary HLH. FHL and MAS were induced in both CXCL9 genetically deficient mice (cxcl9-/-) and controls as well as using AMG487, a pharmacological antagonist of the CXCL9 receptor, CXCR3. Results showed that CXCL9 genetic deficiency did not improve disease parameters or hepatitis in both models. Consistent with genetic ablation of CXCL9, inhibition of its receptor, CXCR3, by AMG487 did not show any significant effects in the FHL model. Taken together, inhibition of CXCL9-CXCR3 interaction does not ameliorate HLH physiology in general, or hepatitis as a classical target organ of disease.
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Affiliation(s)
- Tamir Diamond
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
| | - Michelle Lau
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeremy Morrissette
- Department of Immunology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Niansheng Chu
- Division of Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward M Behrens
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Division of Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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4
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Duan M, Liu X, Yang Y, Zhang Y, Wu R, Lv Y, Lei H. Orchestrated regulation of immune inflammation with cell therapy in pediatric acute liver injury. Front Immunol 2023; 14:1194588. [PMID: 37426664 PMCID: PMC10323196 DOI: 10.3389/fimmu.2023.1194588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/26/2023] [Indexed: 07/11/2023] Open
Abstract
Acute liver injury (ALI) in children, which commonly leads to acute liver failure (ALF) with the need for liver transplantation, is a devastating life-threatening condition. As the orchestrated regulation of immune hemostasis in the liver is essential for resolving excess inflammation and promoting liver repair in a timely manner, in this study we focused on the immune inflammation and regulation with the functional involvement of both innate and adaptive immune cells in acute liver injury progression. In the context of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, it was also important to incorporate insights from the immunological perspective for the hepatic involvement with SARS-CoV-2 infection, as well as the acute severe hepatitis of unknown origin in children since it was first reported in March 2022. Furthermore, molecular crosstalk between immune cells concerning the roles of damage-associated molecular patterns (DAMPs) in triggering immune responses through different signaling pathways plays an essential role in the process of liver injury. In addition, we also focused on DAMPs such as high mobility group box 1 (HMGB1) and cold-inducible RNA-binding protein (CIRP), as well as on macrophage mitochondrial DNA-cyclic GMP-AMP synthase (cGAS)-stimulator of interferon genes (STING) signaling pathway in liver injury. Our review also highlighted novel therapeutic approaches targeting molecular and cellular crosstalk and cell-based therapy, providing a future outlook for the treatment of acute liver injury.
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Affiliation(s)
- Mingyue Duan
- Department of Clinical Laboratory, The Affiliated Children’s Hospital of Xi’an Jiaotong University, Xi’an, China
- Key Laboratory of Precision Medicine to Pediatric Diseases of Shaanxi Province, Shaanxi Institute for Pediatric Diseases, The Affiliated Children’s Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Xiaoguai Liu
- Department of Infectious Diseases, The Affiliated Children’s Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Ying Yang
- Key Laboratory of Precision Medicine to Pediatric Diseases of Shaanxi Province, Shaanxi Institute for Pediatric Diseases, The Affiliated Children’s Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yanmin Zhang
- Key Laboratory of Precision Medicine to Pediatric Diseases of Shaanxi Province, Shaanxi Institute for Pediatric Diseases, The Affiliated Children’s Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Rongqian Wu
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yi Lv
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Hong Lei
- Key Laboratory of Precision Medicine to Pediatric Diseases of Shaanxi Province, Shaanxi Institute for Pediatric Diseases, The Affiliated Children’s Hospital of Xi’an Jiaotong University, Xi’an, China
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5
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Chapin CA, Burn TM, Diamond T, Loomes KM, Alonso EM, Behrens EM. Effector memory CD8 T-cells as a novel peripheral blood biomarker for activated T-cell pediatric acute liver failure. PLoS One 2023; 18:e0286394. [PMID: 37267251 PMCID: PMC10237500 DOI: 10.1371/journal.pone.0286394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 05/12/2023] [Indexed: 06/04/2023] Open
Abstract
A distinct phenotype of pediatric acute liver failure (PALF) has been identified, labeled activated T-cell hepatitis. These patients, previously included within the indeterminate group, have evidence of systemic immune activation and liver biopsy specimens with dense infiltration of CD8+ T-cells. We aimed to evaluate the peripheral blood T-cell phenotype in PALF patients with activated T-cell hepatitis compared to indeterminate cause. PALF patients with unknown etiology age 1-17 years were prospectively enrolled between 2017-2020. Within the unknown group, patients were classified as either activated T-cell hepatitis if they had a liver biopsy with dense or moderate CD8 staining and an elevated soluble interleukin-2 receptor level, or they were classified as indeterminate if they did not meet these criteria. Whole blood was collected for flow cytometry and T-cell phenotyping. Four patients with activated T-cell hepatitis and 4 patients with indeterminate PALF were enrolled. Activated T-cell hepatitis patients had significantly greater percentage of CD8 T-cells that were effector memory (TEM) phenotype compared to indeterminate PALF patients (median 66.8% (IQR 57.4-68.7) vs 19.1% (IQR 13.4-25.2), P = 0.03). In addition, CD8+ TEM cells in activated T-cell hepatitis patients were significantly more likely to be CD103 positive, a marker of tissue resident memory T-cells, compared to indeterminate PALF patients (median 12.4% (IQR 9.5-14.7) vs 4.7% (IQR 4.5-5.3), P = 0.03). We found patients with activated T-cell hepatitis can be identified by the unique pattern of increased percentage of peripheral blood effector memory CD8+ CD103+ T-cells. These findings will guide future studies exploring the T-cell phenotype for these patients and whether they may respond to directed immunosuppressive therapies.
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Affiliation(s)
- Catherine A. Chapin
- Department of Pediatrics, Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, Illinois, United States of America
| | - Thomas M. Burn
- Department of Pediatrics, Perelman School of Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Tamir Diamond
- Department of Pediatrics, Perelman School of Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Kathleen M. Loomes
- Department of Pediatrics, Perelman School of Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Estella M. Alonso
- Department of Pediatrics, Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, Illinois, United States of America
| | - Edward M. Behrens
- Department of Pediatrics, Perelman School of Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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6
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Banc-Husu AM, Moulton EA, Shiau H, Gutierrez Sanchez LH, Desai MS, Cerminara D, Munoz FM, Buffaloe LM, Valencia-Deray KG, Galvan NTN, Bhatnagar J, Estetter L, Rassaei N, Reagan-Steiner S, Wicker J, Dunn JJ, Allen CE, Patel KR, Harpavat S, Goss JA, Leung DH. Acute liver failure and unique challenges of pediatric liver transplantation amidst a worldwide cluster of adenovirus-associated hepatitis. Am J Transplant 2023; 23:93-100. [PMID: 36695626 DOI: 10.1016/j.ajt.2022.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 01/13/2023]
Abstract
Investigation into a recent cluster of acute hepatitis in children from the southeastern United States identified human adenovirus (HAdV) DNAemia in all 9 cases. Molecular genotyping in 5 of 9 (56%) children identified HAdV type 41 in all cases (100%). Importantly, 2 children from this cluster progressed rapidly to pediatric acute liver failure (PALF) and required liver transplantation. HAdV type 41, a known cause of self-limited gastroenteritis, has not previously been associated with severe cholestatic hepatitis and liver failure in healthy children. Adenovirus polymerase chain reaction assay and sequencing of amplicons performed on DNA extracted from formalin-fixed, paraffin-embedded liver tissue also identified adenovirus species F (HAdV type 40 or 41) in these 2 children with PALF. Transplant considerations and successful liver transplantation in such situations remain scarce. In this report, we describe the clinical course, laboratory results, liver pathology, and treatment of 2 children with PALF associated with HAdV type 41, one of whom developed secondary hemophagocytic lymphohistiocytosis. Their successful posttransplant outcomes demonstrate the importance of early multidisciplinary medical management and the feasibility of liver transplantation in some children with PALF and HAdV DNAemia.
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Affiliation(s)
- Anna M Banc-Husu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Elizabeth A Moulton
- Division of Infectious Disease, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Henry Shiau
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA; Children's of Alabama, Birmingham, Alabama, USA
| | - Luz Helena Gutierrez Sanchez
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA; Children's of Alabama, Birmingham, Alabama, USA
| | - Moreshwar S Desai
- Pediatric Critical Care and Liver ICU, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Dana Cerminara
- Department of Pharmacy, Texas Children's Hospital, Houston, Texas, USA
| | - Flor M Munoz
- Division of Infectious Disease, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Leanne M Buffaloe
- Division of Infectious Disease, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Kristen G Valencia-Deray
- Division of Infectious Disease, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - N Thao N Galvan
- Division of Abdominal Transplantation and Hepatobiliary Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Julu Bhatnagar
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lindsey Estetter
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Negar Rassaei
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sarah Reagan-Steiner
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jason Wicker
- Children's of Alabama, Birmingham, Alabama, USA; Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James J Dunn
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Carl E Allen
- Division of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Kalyani R Patel
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sanjiv Harpavat
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - John A Goss
- Division of Abdominal Transplantation and Hepatobiliary Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.
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7
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Zhang L, Ma T, Yan Y, Chen YY, Zhu XH, Ren HZ. The Diagnostic and Therapeutic Value of NCAPG as a Proposed Biomarker Candidate in Acute Liver Failure. Comb Chem High Throughput Screen 2023; 26:2738-2748. [PMID: 37066775 DOI: 10.2174/1386207326666230416165707] [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: 09/02/2022] [Revised: 01/26/2023] [Accepted: 02/02/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Acute Liver Failure (ALF) is a difficult problem to solve in clinical practice. The presence of non-SMC condensin I complex subunit G (NCAPG) has previously been linked to vascular invasion of digestive system tumors, foreshadowing poor prognosis. Its role in ALF biology, however, remains unknown. This article explores the role of NCAPG as a potential biomarker candidate for the accurate diagnosis and targeted treatment of ALF. METHODS The study included transcription data (GSE14668, GSE38941, GSE62029, GSE96851, and GSE120652) of ALF, normal tissues, and clinical samples, where NCAPG was selected as the differential gene by the "DESeq2" R package to analyze the immune cell functions and signal pathways. Furthermore, RT-qPCR and Western blot analyses were used to confirm the RNA and protein levels of NCAPG in ALF cell models, respectively. RESULTS Bioinformatics analysis revealed that NACPG was up-regulated in ALF tissues, and the functional signaling pathway was primarily associated with immune infiltration. Based on the results of clinical samples, we suggest that NCAPG was overexpressed in ALF tissues. We also found that the expression of NCAPG increased with the degree of liver injury in vitro. Enrichment analysis suggested that NCAPG influenced ALF as a PI3K/AKT pathway activator. CONCLUSION Our study suggests that NCAPG is a preliminary tool for the diagnosis of ALF. It can affect ALF via the PI3K/AKT pathway and is a potential therapeutic target to improve prognosis.
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Affiliation(s)
- Lu Zhang
- Nanjing Drum Tower Hospital, Clinical College of Xuzhou Medical University, Xuzhou, China
| | - Tao Ma
- Department of Gastroenterology, Affiliated Hospital of Nantong University, Nantong, China
| | - Yang Yan
- Department of Gastroenterology, Affiliated Hospital of Nantong University, Nantong, China
| | - Yu-Yan Chen
- Department of Hepatobiliary Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Xin-Hua Zhu
- Department of Hepatobiliary Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Hao-Zhen Ren
- Department of Hepatobiliary Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
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Diamond T, Burn TN, Nishiguchi MA, Minichino D, Chase J, Chu N, Kreiger PA, Behrens EM. Familial hemophagocytic lymphohistiocytosis hepatitis is mediated by IFN-γ in a predominantly hepatic-intrinsic manner. PLoS One 2022; 17:e0269553. [PMID: 35671274 PMCID: PMC9173616 DOI: 10.1371/journal.pone.0269553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/23/2022] [Indexed: 12/03/2022] Open
Abstract
Interferon gamma (IFN-γ) is the main cytokine driving organ dysfunction in Familial Hemophagocytic Lymphohistiocytosis (FHL). Blockade of IFN-γ pathway ameliorates FHL hepatitis, both in animal models and in humans with FHL. Hepatocytes are known to express IFN-γ receptor (IFN-γ-R). However, whether IFN-γ induced hepatitis in FHL is a lymphocyte or liver intrinsic response to the cytokine has yet to be elucidated. Using a IFNgR-/- bone marrow chimeric model, this study showed that non-hematopoietic IFN-γ response is critical for development of FHL hepatitis in LCMV-infected Prf1-/- mice. Lack of hepatic IFN-γ responsiveness results in reduced hepatitis as measured by hepatomegaly, alanine aminotransferase (ALT) levels and abrogated histologic endothelial inflammation. In addition, IFN-γ non-hematopoietic response was critical in activation of lymphocytes by soluble interleukin 2 receptor (sIL-2r) and recruitment of CD8+ effector T lymphocytes (CD8+ CD44hi CD62Llo) (Teff) and inflammatory monocytes. Lastly, non-hematopoietic IFN-γ response results in increased hepatic transcription of type 1 immune response and oxidative stress response pathways, while decreasing transcription of genes involved in extracellular matrix (ECM) production. In summary, these findings demonstrate that there is a hepatic transcriptional response to IFN-γ, likely critical in the pathogenesis of FHL hepatitis and hepatic specific responses could be a therapeutic target in this disorder.
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Affiliation(s)
- Tamir Diamond
- Division of Gastroenterology Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Thomas N. Burn
- Perlman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Mailyn A. Nishiguchi
- Perlman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Danielle Minichino
- Perlman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Julie Chase
- Division of Rheumatology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Niansheng Chu
- Division of Rheumatology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Portia A. Kreiger
- Department of Pathology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Edward M. Behrens
- Division of Rheumatology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
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9
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Chapin CA, Taylor SA, Malladi P, Neighbors K, Melin-Aldana H, Kreiger PA, Bowsher N, Schipma MJ, Loomes KM, Behrens EM, Alonso EM. Transcriptional Analysis of Liver Tissue Identifies Distinct Phenotypes of Indeterminate Pediatric Acute Liver Failure. Hepatol Commun 2021; 5:1373-1384. [PMID: 34430782 PMCID: PMC8369940 DOI: 10.1002/hep4.1726] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/01/2021] [Indexed: 02/04/2023] Open
Abstract
Many patients with indeterminate pediatric acute liver failure (PALF) have evidence of T-cell driven immune injury; however, the precise inflammatory pathways are not well defined. We have characterized the hepatic cytokine and transcriptional signatures of patients with PALF. A retrospective review was performed on 22 children presenting with indeterminate (IND-PALF; n = 17) or other known diagnoses (DX-PALF; n = 6) with available archived liver tissue. Specimens were stained for clusters of differentiation 8 (CD8) T cells and scored as dense, moderate, or minimal. Measurement of immune analytes and RNA sequencing (RNA-seq) was performed on whole-liver tissue. Immune analyte data were analyzed by principal component analysis, and RNA-seq was analyzed by unsupervised hierarchical clustering, differential gene expression, and gene-set enrichment analysis. Most patients with IND-PALF (94%) had dense/moderate CD8 staining and were characterized by Th1 immune analytes including tumor necrosis factor α, interferon γ (IFN-γ), interleukin (IL) 1β, IL-12, C-X-C motif chemokine ligand (CXCL) 9, and CXCL12. Transcriptional analyses identified two transcriptional PALF phenotypes. Most patients in group 1 (91%) had IND-PALF and dense/moderate CD8 staining. This group was characterized by increased expression of genes and cell subset-specific signatures related to innate inflammation, T-cell activation, and antigen stimulation. Group 1 expressed significantly higher levels of gene signatures for regulatory T cells, macrophages, Th1 cells, T effector memory cells, cytotoxic T cells, and activated dendritic cells (adjusted P < 0.05). In contrast, patients in group 2 exhibited increased expression for genes involved in metabolic processes. Conclusion: Patients with IND-PALF have evidence of a Th1-mediated inflammatory response driven by IFN-γ. Transcriptional analyses suggest that a complex immune network may regulate an immune-driven PALF phenotype with less evidence of metabolic processes. These findings provide insight into mechanisms of hepatic injury in PALF, areas for future research, and potential therapeutic targets.
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Affiliation(s)
- Catherine A Chapin
- Department of PediatricsNorthwestern UniversityFeinberg School of MedicineAnn & Robert H. Lurie Children's Hospital of ChicagoChicagoILUSA
| | - Sarah A Taylor
- Department of PediatricsNorthwestern UniversityFeinberg School of MedicineAnn & Robert H. Lurie Children's Hospital of ChicagoChicagoILUSA
| | - Padmini Malladi
- Department of PediatricsNorthwestern UniversityFeinberg School of MedicineAnn & Robert H. Lurie Children's Hospital of ChicagoChicagoILUSA
| | - Katie Neighbors
- Department of PediatricsNorthwestern UniversityFeinberg School of MedicineAnn & Robert H. Lurie Children's Hospital of ChicagoChicagoILUSA
| | - Hector Melin-Aldana
- Department of Pathology and Laboratory MedicineNorthwestern UniversityFeinberg School of MedicineAnn & Robert H. Lurie Children's Hospital of ChicagoChicagoILUSA
| | - Portia A Kreiger
- Department of Pathology and Laboratory MedicineUniversity of PennsylvaniaPerelman School of MedicineThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Nina Bowsher
- Preventative MedicineBiostatistics Collaboration CenterNorthwestern UniversityFeinberg School of MedicineChicagoILUSA
| | - Matthew J Schipma
- Next Generation Sequencing CoreNorthwestern UniversityFeinberg School of MedicineChicagoILUSA
| | - Kathleen M Loomes
- Department of PediatricsUniversity of PennsylvaniaPerelman School of MedicineThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Edward M Behrens
- Department of PediatricsUniversity of PennsylvaniaPerelman School of MedicineThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Estella M Alonso
- Department of PediatricsNorthwestern UniversityFeinberg School of MedicineAnn & Robert H. Lurie Children's Hospital of ChicagoChicagoILUSA
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10
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Leonis MA, Miethke AG, Fei L, Maynor S, Chapin CA, Bleesing JJ, Alonso EM, Squires RH. Four Biomarkers Linked to Activation of Cluster of Differentiation 8-Positive Lymphocytes Predict Clinical Outcomes in Pediatric Acute Liver Failure. Hepatology 2021; 73:233-246. [PMID: 32294261 PMCID: PMC8530172 DOI: 10.1002/hep.31271] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/20/2020] [Accepted: 03/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Immune dysregulation contributes to the pathogenesis of pediatric acute liver failure (PALF). Our aim was to identify immune activation markers (IAMs) in PALF that are associated with a distinct clinical phenotype and outcome. APPROACH AND RESULTS Among 47 PALF study participants, 12 IAMs collected ≤6 days after enrollment were measured by flow cytometry and IMMULITE assay on blood natural killer and cluster of differentiation 8-positive (CD8+ ) lymphocytes and subjected to unsupervised hierarchical analyses. A derivation cohort using 4 of 12 IAMs which were available in all participants (percent perforin-positive and percent granzyme-positive CD8 cells, absolute number of CD8 cells, soluble interleukin-2 receptor level) were sufficient to define high (n = 10), medium (n = 15), and low IAM (n = 22) cohorts. High IAM was more frequent among those with indeterminate etiology than those with defined diagnoses (80% versus 20%, P < 0.001). High IAM was associated with higher peak serum total bilirubin levels than low IAM (median peak 21.7 versus 4.8 mg/dL, P < 0.001) and peak coma grades. The 21-day outcomes differed between groups, with liver transplantation more frequent in high IAM participants (62.5%) than those with medium (28.2%) or low IAM (4.8%) (P = 0.002); no deaths were reported. In an independent validation cohort (n = 71) enrolled in a prior study, segregation of IAM groups by etiology, initial biochemistries, and short-term outcomes was similar, although not statistically significant. High serum aminotransferases, total bilirubin levels, and leukopenia at study entry predicted a high immune activation profile. CONCLUSION Four circulating T-lymphocyte activation markers identify a subgroup of PALF participants with evidence of immune activation associated with a distinct clinical phenotype and liver transplantation; these biomarkers may identify PALF participants eligible for future clinical trials of early targeted immunosuppression.
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Affiliation(s)
- Mike A. Leonis
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham and Children’s of Alabama, Birmingham, AL
| | - Alexander G. Miethke
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Lin Fei
- Department of Pediatrics, Division of Biostatistics and Epidemiology, University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Sean Maynor
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Catherine A. Chapin
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Jacob J.H. Bleesing
- Department of Pediatrics, Division of Bone Marrow Transplantation & Immune Deficiency, University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Estella M. Alonso
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Robert H. Squires
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA
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11
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Activated CD8 T-cell Hepatitis in Children With Indeterminate Acute Liver Failure: Results From a Multicenter Cohort. J Pediatr Gastroenterol Nutr 2020; 71:713-719. [PMID: 32796431 DOI: 10.1097/mpg.0000000000002893] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In many pediatric acute liver failure (PALF) cases, a diagnosis is not identified, and the etiology is indeterminate (IND-PALF). Our pilot study found dense CD8 T-cell infiltrates and increased T-cell clonality in liver specimens from IND-PALF patients. We aimed to validate these findings in a multicenter cohort with investigators blinded to diagnosis. METHODS PALF Study Group registry subjects with IND-PALF (n = 37) and known diagnoses (DX-PALF) (n = 18), ages 1 to 17 years, with archived liver tissue were included. Liver tissue slides were stained for T cells (CD8 and CD4), B cells (CD20), macrophages (CD163), perforin, and tissue resident-memory T cells (Trm, CD103), and scored as minimal, moderate, or dense. Lymphocytes were isolated from frozen liver tissue for T-cell receptor beta (TCRβ) sequencing. RESULTS Dense hepatic CD8 staining was found in significantly more IND-PALF (n = 29, 78%) compared with DX-PALF subjects (n = 5, 28%) (P = 0.001). IND-PALF subjects were more likely to have dense or moderate perforin (88% vs 50%, P = 0.03) and CD103 (82% vs 40%, P = 0.02) staining compared with DX-PALF subjects. TCRβ sequencing of 15 IND-PALF cases demonstrated increased clonal overlap compared with 6 DX-PALF cases (P = 0.002). CONCLUSIONS Dense infiltration of effector Trm CD8 T cells characterizes liver tissue from IND-PALF subjects. Increased clonality suggests the T-cell expansion is antigen(s)-driven as opposed to a nonspecific inflammatory response. These findings support CD8 staining as a new biomarker of the activated CD8 T-cell PALF phenotype. Future studies are needed to characterize potential antigens, host risk factors, and inflammatory pathways with the goal of developing targeted therapies.
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12
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Chen H, Zhao W, Zhang Y, Guo Y, Luo W, Wang X, Nie Y, Ye M, Huang C, Wang D, Chen M, He X, Zhao Q. Systematic analysis on multiple Gene Expression Omnibus data sets reveals fierce immune response in hepatitis B virus-related acute liver failure. J Cell Mol Med 2020; 24:9798-9809. [PMID: 32686296 PMCID: PMC7520256 DOI: 10.1111/jcmm.15561] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/26/2020] [Accepted: 06/14/2020] [Indexed: 12/17/2022] Open
Abstract
Acute liver failure (ALF) caused by hepatitis B virus (HBV) is common type of liver failure in the world, with high morbidity and mortality rates. However, the prevalence, genetic background and factors determining the development of HBV‐related ALF are rarely studied. In this study, we examined three Gene Expression Omnibus (GEO) data sets by bioinformatics analysis to identify differentially expressed genes (DEGs), key biological processes and pathways. Immune infiltration analysis showed high immune cells infiltration in HBV‐related ALF tissue. We then confirmed natural killer cells and macrophages infiltration in clinical samples by immunohistochemistry assay, implying these cells play a significant role in HBV‐ALF. We found 1277 genes were co‐up‐regulated and that 1082 genes were co‐down‐regulated in the 3 data sets. Inflammation‐related pathways were enriched in the co‐up‐regulated genes and synthetic metabolic pathways were enriched in the co‐down‐regulated genes. WGCNA also revealed a key module enriching in immune inflammation response and identified 10 hub genes, differentially expressed in an independent data set. In conclusion, we identified fierce immune inflammatory response to elucidate the immune‐driven mechanism of HBV‐ALF and 10 hub genes based on gene expression profiles.
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Affiliation(s)
- Huadi Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Wenting Zhao
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Yixi Zhang
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yiwen Guo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Weixin Luo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Xiaobo Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Yu Nie
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Maodong Ye
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Changjun Huang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Dongping Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Maogen Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Xiaoshun He
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Qiang Zhao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
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13
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Jordan MB, Allen CE, Greenberg J, Henry M, Hermiston ML, Kumar A, Hines M, Eckstein O, Ladisch S, Nichols KE, Rodriguez-Galindo C, Wistinghausen B, McClain KL. Challenges in the diagnosis of hemophagocytic lymphohistiocytosis: Recommendations from the North American Consortium for Histiocytosis (NACHO). Pediatr Blood Cancer 2019; 66:e27929. [PMID: 31339233 PMCID: PMC7340087 DOI: 10.1002/pbc.27929] [Citation(s) in RCA: 196] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/10/2019] [Accepted: 06/28/2019] [Indexed: 12/15/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of pathologic immune activation, often associated with genetic defects of lymphocyte cytotoxicity. Though a distinctive constellation of features has been described for HLH, diagnosis remains challenging as patients have diverse presentations associated with a variety of triggers. We propose two concepts to clarify how HLH is diagnosed and treated: within the broader syndrome of HLH, "HLH disease" should be distinguished from "HLH disease mimics" and HLH subtypes should be categorized by specific etiologic associations, not the ambiguous dichotomy of "primary" and "secondary." We provide expert-based advice regarding the diagnosis and initiation of treatment for patients with HLH, rooted in improved understanding of its pathophysiology.
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Affiliation(s)
- Michael B. Jordan
- Division of Immunobiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Carl E. Allen
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Jay Greenberg
- Division of Hematology, Children’s National Medical Center, Washington, DC
| | - Michael Henry
- Center for Cancer and Blood Disorders, Phoenix Children’s Hospital, University of Arizona College of Medicine, Tucson, Arizona
| | - Michelle L. Hermiston
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California San Francisco, San Francisco, California
| | - Ashish Kumar
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Melissa Hines
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Olive Eckstein
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Stephan Ladisch
- Center for Cancer and Immunology Research, Children’s National Medical Center and George Washington University School of Medicine, Washington, DC
| | - Kim E. Nichols
- Division of Cancer Predisposition, Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Carlos Rodriguez-Galindo
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Birte Wistinghausen
- Division of Oncology, Center for Cancer and Blood Disorders, Children’s National Health System, Washington, DC
| | - Kenneth L. McClain
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Additional corresponding author, Kenneth L. McClain, 6701 Fannin St. Suite 1510, Houston, TX 77030,
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14
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Chapin CA, Horslen SP, Squires JE, Lin H, Blondet N, Mohammad S, Alonso EM. Corticosteroid Therapy for Indeterminate Pediatric Acute Liver Failure and Aplastic Anemia with Acute Hepatitis. J Pediatr 2019; 208:23-29. [PMID: 30770193 DOI: 10.1016/j.jpeds.2018.12.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/16/2018] [Accepted: 12/18/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To examine the characteristics and outcomes of a multicenter patient cohort with indeterminate pediatric acute liver failure (IND-PALF) and with aplastic anemia with acute hepatitis treated with corticosteroids. STUDY DESIGN Retrospective study of patients age 1-17 years with IND-PALF and aplastic anemia with acute hepatitis who presented between 2009 and 2018 to 1 of 4 institutions and were treated with corticosteroids for presumed immune dysregulation. RESULTS Of 28 patients with IND-PALF (median of 4.0 years of age [range 1-16] and 71% male) 71% (n = 20) were treated with 0.5-4 mg/kg/day of intravenous methylprednisolone, and 8 patients received 10 mg/kg/day followed by a taper. By 21 days postcorticosteroid initiation, 14 patients (50%) underwent liver transplantation, 13 patients (46%) recovered with their native liver, and 1 patient (4%) died. Patients who recovered with their native liver received a median of 139 days (range 19-749) of corticosteroid therapy, with a median of 12 days (range 1-240) to international normalized ratio ≤1.2. Patients with aplastic anemia with acute hepatitis (n = 6; median of 9.5 years of age [range 1-12], 83% male), received 1-2 mg/kg/day of methylprednisolone for a median of 100 days (range 63-183), and all recovered with their native liver. One patient with IND-PALF and 2 patients with aplastic anemia with acute hepatitis developed a serious infection within 90 days postcorticosteroid initiation. CONCLUSIONS Many patients with IND-PALF or aplastic anemia with acute hepatitis that were treated with corticosteroids improved, but survival with native liver may not be different from historical reports. A randomized controlled trial exploring the benefits and risks of steroid therapy is needed before it is adopted broadly.
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Affiliation(s)
- Catherine A Chapin
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Simon P Horslen
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - James E Squires
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Henry Lin
- Department of Pediatrics; The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Niviann Blondet
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Saeed Mohammad
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Estella M Alonso
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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15
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Zhang LN, Guo W, Zhu JH, Guo Y. Successful rescue of acute liver failure and hemophagocytic lymphohistiocytosis following varicella infection: A case report and review of literature. World J Clin Cases 2018; 6:659-665. [PMID: 30430121 PMCID: PMC6232574 DOI: 10.12998/wjcc.v6.i13.659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/10/2018] [Accepted: 10/09/2018] [Indexed: 02/05/2023] Open
Abstract
Herein we report a case of acute liver failure (ALF) and hemophagocytic lymphohistiocytosis (HLH) induced by varicella infection, successfully rescued by a combination therapy of acyclovir, supportive care, and immunosuppression with dexamethasone and etoposide. A previously healthy 16-year-old boy presented with generalized rash, fever, severe abdominal pain, and abnormal liver function within 4 d. Chickenpox was suspected, and acyclovir and intravenous immunoglobulin were started on admission. However, the patient’s condition deteriorated overnight with soaring transaminases, severe coagulopathy and encephalopathy. On the fourth day of admission, pancytopenia emerged, accompanied by hypofibrinogenemia and hyperferritinemia. The patient was diagnosed with ALF. He also met the diagnostic criteria of HLH according to the HLH-2004 guideline. Polymerase chain reaction (PCR) amplifications of varicella-zoster virus (VZV) were positive, confirming that VZV was a causative trigger for ALF and HLH. In view of the devastating immune activation in HLH, immunosuppression therapy with dexamethasone and etoposide was administered, in addition to high dose acyclovir. The patient’s symptoms improved dramatically and he finally made a full recovery. To our knowledge, this is only the second report of a successful rescue of ALF associated with HLH, without resorting to liver transplantation. The first case was reported in a neonate infected by herpes simplex virus-1. However, survival data in older children and adults are lacking, most of whom died or underwent liver transplantation. Our report emphasizes the clinical vigilance for the possible presence of HLH, and the necessity of extensive investigation for underlying etiologies in patients presenting with indeterminate ALF. Early initiation of specific therapy targeting the underlying etiology, and watchful immunosuppression such as dexamethasone and etoposide, together with supportive therapy, are of crucial importance in this life-threatening disorder.
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Affiliation(s)
- Li-Na Zhang
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing 100044, China
| | - Wei Guo
- Department of Emergency, Peking University People’s Hospital, Beijing 100044, China
| | - Ji-Hong Zhu
- Department of Emergency, Peking University People’s Hospital, Beijing 100044, China
| | - Yang Guo
- Department of Emergency, Peking University People’s Hospital, Beijing 100044, China
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16
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Chapin CA, Mohammad S, Bass LM, Taylor SA, Kelly S, Alonso EM. Liver Biopsy Can Be Safely Performed in Pediatric Acute Liver Failure to Aid in Diagnosis and Management. J Pediatr Gastroenterol Nutr 2018; 67:441-445. [PMID: 30028827 DOI: 10.1097/mpg.0000000000002096] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Liver biopsy can be a valuable tool to help determine the etiology of pediatric acute liver failure (PALF), but is often not performed due to safety concerns. The primary aim was to describe the incidence of major complications after liver biopsy performed in the setting of PALF. METHODS Medical records from 2006 to 2016 were reviewed. Patients age 0 to 17 years, who met criteria for PALF, and had a liver biopsy performed while their international normalized ratio (INR) was ≥1.5 were included. RESULTS A total of 26 cases of liver biopsy in the setting of PALF were identified. The majority (n = 22, 85%) of patients had primary liver disease. Most biopsies (n = 17, 65%) were performed by the transjugular route, with 5 (19%) performed percutaneously under ultrasound guidance and 4 (15%) during a surgical procedure. Median INR before biopsy was 2.1 (IQR = 1.73-2.9). Blood products were given before or during the procedure in 23 (88%) cases. One patient (3.8%) had a major complication of biopsy-associated bleeding requiring a blood transfusion. An additional 3 patients had a hemoglobin decrease of 2.1 to 2.9 g/dL post-biopsy that was attributed to the procedure but no interventions were necessary. Biopsy results contributed to establishing a diagnosis in 62% (n = 16) of cases, and influenced treatment decisions in 9 of those cases. CONCLUSIONS Liver biopsy is safe in the majority of patients with PALF and associated with infrequent major complications. Clinicians should consider performing liver biopsy in this setting, especially when the transjugular approach is feasible, since findings may guide diagnosis and therapy.
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Affiliation(s)
- Catherine A Chapin
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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17
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Chapin CA, Burn T, Meijome T, Loomes KM, Melin-Aldana H, Kreiger PA, Whitington PF, Behrens EM, Alonso EM. Indeterminate pediatric acute liver failure is uniquely characterized by a CD103 + CD8 + T-cell infiltrate. Hepatology 2018; 68:1087-1100. [PMID: 29603342 DOI: 10.1002/hep.29901] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/28/2018] [Accepted: 03/23/2018] [Indexed: 12/16/2022]
Abstract
UNLABELLED The cause of pediatric acute liver failure (PALF) is unknown in up to 40% of cases. Evidence suggests that aberrant immune system activation may play a role. We hypothesized that indeterminate PALF cases would exhibit a unique pattern of hepatic inflammation. This was a retrospective and prospective study of PALF cases due to indeterminate (iPALF), autoimmune hepatitis, or known diagnosis (dPALF) etiology. Liver tissue sections were stained with immunohistochemical markers for cytotoxic T-cells (cluster of differentiation 8 [CD8]), perforin, and tissue resident memory T-cells (CD103) and scored as minimal, moderate, or dense. Lymphocytes were isolated from liver tissue for T-cell receptor beta sequencing and flow-cytometric studies. Thirty-three iPALF, 9 autoimmune hepatitis, and 14 dPALF cases were included. Dense hepatic infiltrates of CD8+ T-cells were found in 27 (82%) iPALF cases compared to 1 (7%) dPALF case (P < 0.0001). Perforin staining was dense or moderate in 19 (73%) of 26 iPALF cases compared to minimal in all 7 dPALF cases (P = 0.004); 16 (62%) of 26 iPALF cases had dense CD103 staining compared to none of the 6 dPALF cases (P = 0.001). T-cell receptor beta sequencing of iPALF cases demonstrated increased clonality compared to dPALF and control cases. Flow cytometry and immunohistochemistry revealed that iPALF intrahepatic leukocytes were predominantly tissue resident memory CD8+ T-cells. CONCLUSION Indeterminate PALF is characterized by a dense CD8+ T-cell hepatic infiltrate consistent with expansion of a tissue resident memory T-cell phenotype; CD8+ T-cells are a biomarker of immune dysregulation in iPALF and may be used to better identify and define this group. (Hepatology 2018).
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Affiliation(s)
- Catherine A Chapin
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Thomas Burn
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Tomas Meijome
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kathleen M Loomes
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hector Melin-Aldana
- Department of Pathology and Laboratory Medicine, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Portia A Kreiger
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Peter F Whitington
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Edward M Behrens
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Estella M Alonso
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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18
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Clinical utility of soluble interleukin-2 receptor in hemophagocytic syndromes: a systematic scoping review. Ann Hematol 2017; 96:1241-1251. [PMID: 28497365 DOI: 10.1007/s00277-017-2993-y] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/11/2017] [Indexed: 12/22/2022]
Abstract
The serum-soluble interleukin-2 receptor (sIL-2r) level is considered an important diagnostic test and disease marker in hemophagocytic syndromes/hemophagocytic lymphohistiocytosis (HPS/HLH). However, this cytokine receptor is rarely measured in clinical practice and has been excluded from recent diagnostic/classification criteria such as the HScore and macrophage activation syndrome (MAS) 16. We performed a systematic scoping review of 64 articles (1975-2016) examining the clinical utility of sIL-2r in HPS/HLH. Twenty-two articles describe sIL-2r as a sensitive diagnostic marker for HLH, but only three distinct datasets actually address sensitivity. The original HLH-2004 Guidelines reported sensitivity of 93% and specificity of 100% for sIL-2r ≥ 2400, based on a pediatric dataset (n = 152) which is published for the first time in this review. Two pediatric studies reported sensitivity of 89% for sIL-2r ≥ 2400 in diagnosis of MAS complicating juvenile idiopathic arthritis (JIA) (n = 27) and 88% for secondary HLH in acute liver failure (n = 9). Twenty articles described sIL-2r as a dynamic marker of disease activity that falls with response to treatment, and 15 described high initial sIL-2r levels >10,000 U/mL as a poor prognostic marker. The ability of sIL-2r to distinguish between subtypes of HPS/HLH was inconsistent. This review confirms the importance of soluble IL-2r as a diagnostic and disease marker in HPS/HLH, but also reveals the need for more primary data about its performance characteristics, particularly in adults. More emphasis should be made in including this simple, inexpensive test in clinical practice and studies of HPS/HLH.
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19
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Alonso EM, Horslen SP, Behrens EM, Doo E. Pediatric acute liver failure of undetermined cause: A research workshop. Hepatology 2017; 65:1026-1037. [PMID: 27862115 PMCID: PMC5372202 DOI: 10.1002/hep.28944] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 10/13/2016] [Accepted: 11/02/2016] [Indexed: 12/15/2022]
Abstract
UNLABELLED Pediatric acute liver failure (PALF) is a potentially devastating condition that occurs in previously healthy children of all ages and frequently leads to a rapid clinical deterioration. An identified cause for liver injury is lacking in approximately 30% of cases. Children with undetermined diagnosis have lower spontaneous survival and higher rates of transplantation and death than other diagnostic groups. A single-day workshop sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases brought together clinicians and basic scientists to integrate aligned research findings and develop a foundation for new mechanistic studies and future treatment trials. The clinical phenotype of indeterminate PALF shares important similarities to the hyperinflammatory state characteristic of hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS). A failure of cytotoxic T cells to limit or contract inflammatory responses may propagate injury and lead to a local and systemic milieu that does not support normal hepatic regeneration. Evidence was presented that bone marrow (BM)-derived Sinusoidal endothelial cell PROgenitor Cells (sprocs) play a vital role in hepatic regeneration. Overwhelming systemic inflammatory responses may suppress mobilization of BM sprocs and dampen hepatic recovery. CONCLUSION Experience gained through treatment trials of HLH and MAS in childhood may inform study design for therapy of PALF. Successful approaches to limiting neuroinflammation through reduction of systemic inflammation and standardized neuroprotection protocols that limit glial injury could significantly improve intact survival. Finally, given that PALF is a rare disease, investigative efforts must include broad multicenter collaboration and careful stewardship of biorepository specimens. (Hepatology 2017;65:1026-1037).
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Affiliation(s)
- Estella M Alonso
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Pediatrics, Chicago, IL
| | - Simon P Horslen
- Seattle Children’s Hospital, Department of Pediatrics at the University of Washington School of Medicine, Seattle, WA
| | - Edward M Behrens
- Children’s Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania, Philadelphia, PA
| | - Edward Doo
- Liver Diseases Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
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20
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Rood JE, Canna SW, Weaver LK, Tobias JW, Behrens EM. IL-10 distinguishes a unique population of activated, effector-like CD8 + T cells in murine acute liver inflammation. J Leukoc Biol 2016; 101:1037-1044. [PMID: 28034913 DOI: 10.1189/jlb.3a0916-221rr] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 11/23/2016] [Accepted: 12/06/2016] [Indexed: 01/06/2023] Open
Abstract
Immune-mediated liver injury is a central feature of hyperinflammatory diseases, such as hemophagocytic syndromes, yet the immunologic mechanisms underlying those processes are incompletely understood. In this study, we used the toll-like receptor 9 (TLR9)-mediated model of a hemophagocytic syndrome known as macrophage activation syndrome (MAS) to dissect the predominant immune cell populations infiltrating the liver during inflammation. We identified CD8+ T cells that unexpectedly produce interleukin-10 (IL-10) in addition to interferon-γ (IFN-γ) as a major hepatic population induced by TLR9 stimulation. Despite their ability to produce this anti-inflammatory cytokine, IL-10+ hepatic CD8+ T cells in TLR9-MAS mice did not resemble CD8+ T suppressor cells. Instead, the induction of these cells occurred independently of antigen stimulation and was partially dependent on IFN-γ. IL-10+ hepatic CD8+ T cells demonstrated an activated phenotype and high turnover rate, consistent with an effector-like identity. Transcriptional analysis of this population confirmed a gene signature of effector CD8+ T cells yet suggested responsiveness to liver injury-associated growth factors. Together, these findings suggest that IL-10+ CD8+ T cells induced by systemic inflammation to infiltrate the liver have initiated an inflammatory, rather than regulatory, program and may thus have a pathogenic role in severe, acute hepatitis.
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Affiliation(s)
- Julia E Rood
- Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Scott W Canna
- Molecular Immunology and Inflammation Branch, National Institute for Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA; and
| | - Lehn K Weaver
- Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John W Tobias
- Molecular Profiling Core, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward M Behrens
- Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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21
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Amir AZ, Ling SC, Naqvi A, Weitzman S, Fecteau A, Grant D, Ghanekar A, Cattral M, Nalli N, Cutz E, Kamath B, Jones N, De Angelis M, Ng V, Avitzur Y. Liver transplantation for children with acute liver failure associated with secondary hemophagocytic lymphohistiocytosis. Liver Transpl 2016; 22:1245-53. [PMID: 27216884 DOI: 10.1002/lt.24485] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/27/2016] [Accepted: 04/30/2016] [Indexed: 12/12/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening systemic disease, characterized by overwhelming stimulation of the immune system and categorized as primary or secondary types. Occasionally, acute liver failure (ALF) may dominate the clinical presentation. Given the systemic nature of HLH and risk of recurrence, HLH is considered by many a contraindication to liver transplantation (LT). The aim of this study is to review our single-center experience with LT in children with secondary HLH and ALF (HLH-ALF). This is a cross-sectional, retrospective study of children with secondary HLH-ALF that underwent LT in 2005-2014. Of 246 LTs, 9 patients (3 males; median age, 5 years; range, 0.7-15.4 years) underwent LT for secondary HLH-ALF. Disease progression was rapid with median 14 days (range, 6-27 days) between first symptoms and LT. Low fibrinogen/high triglycerides, elevated ferritin, hemophagocytosis on liver biopsy, and soluble interleukin 2 receptor levels were the most commonly fulfilled diagnostic criteria; HLH genetic studies were negative in all patients. Immunosuppressive therapy after LT included corticosteroids adjusted to HLH treatment protocol and tacrolimus. Thymoglobulin (n = 5), etoposide (n = 4), and alemtuzumab (n = 2) were used in cases of recurrence. Five (56%) patients experienced HLH recurrence, 1 requiring repeat LT, and 3 died. Overall graft and patient survival were 60% and 67%, respectively. Six patients are alive and well at a median of 24 months (range, 15-72 months) after transplantation. In conclusion, LT can be beneficial in selected patients with secondary HLH-ALF and can restore good health in an otherwise lethal condition. Liver Transplantation 22 1245-1253 2016 AASLD.
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Affiliation(s)
- Achiya Z Amir
- Division of Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Simon C Ling
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Naqvi
- Haematology and Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Sheila Weitzman
- Haematology and Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Annie Fecteau
- General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David Grant
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mark Cattral
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nadya Nalli
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ernest Cutz
- Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Binita Kamath
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Nicola Jones
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Maria De Angelis
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Vicky Ng
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
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22
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Kulkarni S, Perez C, Pichardo C, Castillo L, Gagnon M, Beck-Sague C, Gereige R, Hernandez E. Use of Pediatric Health Information System database to study the trends in the incidence, management, etiology, and outcomes due to pediatric acute liver failure in the United States from 2008 to 2013. Pediatr Transplant 2015; 19:888-95. [PMID: 26388211 DOI: 10.1111/petr.12596] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2015] [Indexed: 01/13/2023]
Abstract
Data were collected of children admitted with ALF to 16 US pediatric liver transplant centers from 2008 to 2013 using the PHIS for a retrospective analysis of PALF trends. Patient data linked to the principal diagnosis code for acute necrosis of the liver (570.00) were analyzed for the following: demographics, regional differences, changes over time, pharmaceutical trends, procedural trends, associated diagnoses, and patient outcomes. In 52.5% of 583 patients who met the selection criteria for PALF, the etiology remained undetermined. Acetaminophen toxicity (18.7%) was the most common identifiable etiology, and hepatic encephalopathy (38.6%) was the most common complication. Mortality was lower than previously reported; 95.4% survived and 73.2% survived without a liver transplant. Acute respiratory failure (OR = 3.4, p = 0.035), acute kidney injury (OR = 3.6, p = 0.003), and cerebral edema (OR = 3.6, p = 0.02) were independently associated with increased risk of mortality. The use of N-acetylcysteine in non-acetaminophen-related ALF, the use of intracranial pressure monitoring, and the proportion of sepsis decreased significantly during the study period. The PHIS database can be a useful tool to study the future trends of PALF patients.
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Affiliation(s)
- Sakil Kulkarni
- Department of Medical Education, Miami Children's Hospital, Miami, FL, USA
| | - Carla Perez
- Department of Medical Education, Miami Children's Hospital, Miami, FL, USA
| | - Caren Pichardo
- Department of Medical Education, Miami Children's Hospital, Miami, FL, USA
| | - Lina Castillo
- Department of Medical Education, Miami Children's Hospital, Miami, FL, USA
| | - Michael Gagnon
- Department of Quality and Safety, Miami Children's Hospital, Miami, FL, USA
| | - Consuelo Beck-Sague
- Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Rani Gereige
- Department of Medical Education, Miami Children's Hospital, Miami, FL, USA
| | - Erick Hernandez
- Department of Pediatric Gastroenterology, Miami Children's Hospital, Miami, FL, USA
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23
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McKenzie RB, Berquist WE, Nadeau KC, Louie CY, Chen SF, Sibley RK, Glader BE, Wong WB, Hofmann LV, Esquivel CO, Cox KL. Novel protocol including liver biopsy to identify and treat CD8+ T-cell predominant acute hepatitis and liver failure. Pediatr Transplant 2014; 18:503-9. [PMID: 24930635 DOI: 10.1111/petr.12296] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2014] [Indexed: 12/21/2022]
Abstract
In the majority of children with ALF, the etiology is unknown and liver transplantation is often needed for survival. A patient case prompted us to consider that immune dysregulation may be the cause of indeterminate acute hepatitis and liver failure in children. Our study includes nine pediatric patients treated under a multidisciplinary clinical protocol to identify and treat immune-mediated acute liver injury. Patients with evidence of inflammation and no active infection on biopsy received treatment with intravenous immune globulin and methylprednisolone. Seven patients had at least one positive immune marker before or after treatment. All patients had a CD8+ T-cell predominant liver injury that completely or partially responded to immune therapy. Five of the nine patients recovered liver function and did not require liver transplantation. Three of these patients subsequently developed bone marrow failure and were treated with either immunosuppression or stem cell transplant. This series highlights the importance of this tissue-based approach to diagnosis and treatment that may improve transplant-free survival. Further research is necessary to better characterize the immune injury and to predict the subset of patients at risk for bone marrow failure who may benefit from earlier and stronger immunosuppressive therapy.
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Affiliation(s)
- Rebecca B McKenzie
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Stanford School of Medicine, Stanford, CA, USA
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24
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Hadžić N, Dhawan A. Steroids in acute liver failure? J Pediatr 2014; 165:211-2. [PMID: 24837861 DOI: 10.1016/j.jpeds.2014.03.062] [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: 03/13/2014] [Accepted: 03/28/2014] [Indexed: 11/15/2022]
Affiliation(s)
- Nedim Hadžić
- Pediatric Center for Hepatology, Gastroenterology, and Nutrition, King's College Hospital, London, United Kingdom
| | - Anil Dhawan
- Pediatric Center for Hepatology, Gastroenterology, and Nutrition, King's College Hospital, London, United Kingdom
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