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Sankararaman S, Freeman AJ. Early detection of hepatobiliary involvement in cystic fibrosis: Biomarkers, radiologic methods, and genetic influences. Pediatr Pulmonol 2024; 59 Suppl 1:S107-S114. [PMID: 39105338 DOI: 10.1002/ppul.26892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 01/10/2024] [Accepted: 01/21/2024] [Indexed: 08/07/2024]
Abstract
Cystic fibrosis-related hepatobiliary involvement (CFHBI) is a term used to describe a spectrum of hepatobiliary involvement ranging from a transient elevation of transaminase levels to advanced cystic fibrosis-associated liver disease (aCFLD). While CFHBI is common among people with cystic fibrosis (PwCF), aCFLD is rare impacting only approximately 5%-10% of the CF population. After respiratory/cardiorespiratory issues and transplant-related complications, aCFLD is now the 4th leading cause of mortality among PwCF. Additionally, aCFLD is an independent predictor of all-cause mortality and is associated with significant morbidity. Despite this recognition, our ability to predict those patients at greatest risk for aCFLD, identify early aCFLD, and monitor the incremental progression of CFHBI is lacking. Here, we review the strengths and weaknesses of the common biomarkers and imaging modalities used in the evaluation and monitoring of CFHBI, as well as the current understanding of genetic modifiers related to aCFLD.
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Affiliation(s)
- Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
- Case Western Reserve University SOM, Cleveland, Ohio, USA
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Nationwide Children's Hospital, Columbus, Ohio, USA
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2
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Sellers ZM, Assis DN, Paranjape SM, Sathe M, Bodewes F, Bowen M, Cipolli M, Debray D, Green N, Hughan KS, Hunt WR, Leey J, Ling SC, Morelli G, Peckham D, Pettit RS, Philbrick A, Stoll J, Vavrina K, Allen S, Goodwin T, Hempstead SE, Narkewicz MR. Cystic fibrosis screening, evaluation, and management of hepatobiliary disease consensus recommendations. Hepatology 2024; 79:1220-1238. [PMID: 37934656 PMCID: PMC11020118 DOI: 10.1097/hep.0000000000000646] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/11/2023] [Indexed: 11/09/2023]
Abstract
Cystic fibrosis (CF) may cause a spectrum of hepatobiliary complications, including portal hypertension, multilobular cirrhosis, and liver failure. Current guidelines on the detection and monitoring of hepatobiliary complications in CF were published in 1999. The CF Foundation assembled a committee to evaluate research advances and formulate revised guidelines for CF-associated liver disease. A committee of hepatologists, gastroenterologists, pulmonologists, pharmacists, nurses, dietitians, individuals with CF, and the parents of a child with CF devised "population, intervention, comparison, and outcome" questions regarding hepatobiliary disease in CF. PubMed literature searches were performed for each population, intervention, comparison, and outcome question. Recommendations were voted on with 80% agreement required to approve a recommendation. Public comment on initial recommendations was solicited prior to the formulation of final recommendations. Thirty-one population, intervention, comparison, and outcome questions were assembled, 6401 manuscripts were title screened for relevance, with 1053 manuscripts undergoing detailed full-text review. Seven recommendations were approved for screening, 13 for monitoring of existing disease, and 14 for treatment of CF-associated hepatobiliary involvement or advanced liver disease. One recommendation on liver biopsy did not meet the 80% threshold. One recommendation on screening ultrasound was revised and re-voted on. Through a multidisciplinary committee and public engagement, we have assembled updated recommendations and guidance on screening, monitoring, and treatment of CF-associated hepatobiliary involvement and advanced liver disease. While research gaps remain, we anticipate that these recommendations will lead to improvements in CF outcomes through earlier detection and increased evidence-based approaches to monitoring and treatment.
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Affiliation(s)
- Zachary M. Sellers
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, California, USA
| | - David N. Assis
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Shruti M. Paranjape
- Division of Pediatric Pulmonology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Meghana Sathe
- Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, UT Southwestern, Dallas, Texas, USA
| | - Frank Bodewes
- Department of Pediatric Gastroenterology, University Medical Center Groningen, Groningen, The Netherlands
| | - Melissa Bowen
- Department of Advanced Lung Disease and Lung Transplant, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Dominique Debray
- Pediatric Hepatology Unit, AP-HP, HôpitalNecker-Enfants malades, Paris, France
| | - Nicole Green
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Seattle Children’s Hospital and University of Washington, Seattle, Washington State, USA
| | - Kara S. Hughan
- Department of Pediatrics, Division of Pediatric Endocrinology and Metabolism, UPMC Children’s Hospital of Pittsburgh and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - William R. Hunt
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, Emory University, Atlanta, Georgia, USA
| | - Julio Leey
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, Florida, USA
| | - Simon C. Ling
- Department of Paediatrics, Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Giuseppe Morelli
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Daniel Peckham
- Leeds Institute of Medical Research at St. James’s, University of Leeds, Leeds, UK
| | - Rebeca S. Pettit
- Riley Hospital for Children at IU Health, Indianapolis, Indiana, USA
| | - Alexander Philbrick
- Department of Specialty Pharmacy, Northwestern Medicine, Chicago, Illinois, USA
| | - Janis Stoll
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Washington University School of Medicine, St Louis, Missouri, USA
| | - Kay Vavrina
- University of Texas, Health Science Center, San Antonio, Texas, USA
| | - Stacy Allen
- CF Parent Community Advisor to Cystic Fibrosis Foundation, USA
| | - Tara Goodwin
- CF Parent Community Advisor to Cystic Fibrosis Foundation, USA
| | | | - Michael R. Narkewicz
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, Children’s Hospital Colorado, University of Colorado School of, Aurora, Colorado, USA
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Anton-Păduraru DT, Azoicăi AN, Trofin F, Murgu AM, Mîndru DE, Bocec AS, Halițchi COI, Zota GR, Păduraru D, Nastase EV. Diagnosis, Management, and Prognosis of Cystic Fibrosis-Related Liver Disease in Children. Diagnostics (Basel) 2024; 14:538. [PMID: 38473009 DOI: 10.3390/diagnostics14050538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/28/2024] [Accepted: 03/01/2024] [Indexed: 03/14/2024] Open
Abstract
Cystic fibrosis (CF) is a multifaceted disorder predominantly investigated for its pulmonary manifestations, yet patients with CF also exhibit a spectrum of extrapulmonary manifestations, notably those involving the hepatobiliary system. The latter constitutes the third leading cause of morbidity and mortality in individuals with CF. Cystic fibrosis-related liver disease (CFLD), with an escalating prevalence, manifests diverse clinical presentations ranging from hepatomegaly to cirrhosis and hepatopulmonary syndrome. Consequently, early detection and appropriate management are imperative for sustaining the health and influencing the quality of life of CF patients afflicted with CFLD. This review aims to consolidate existing knowledge by providing a comprehensive overview of hepatobiliary manifestations associated with CF. It delineates the clinical hepatobiliary manifestations, diagnostic methodologies, incorporating minimally invasive markers, and therapeutic approaches, encompassing the impact of novel CFTR modulators on CFLD. Given the exigency of early diagnosis and the intricate management of CFLD, a multidisciplinary team approach is essential to optimize care and enhance the quality of life for this subset of patients. In conclusion, recognizing CF as more than solely a pulmonary ailment, the authors underscore the imperative for further clinical investigations to establish a more robust evidence base for CFLD management within the continuum of this chronic disease.
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Affiliation(s)
- Dana-Teodora Anton-Păduraru
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
- "Sf. Maria" Children Emergency Hospital, 700309 Iasi, Romania
| | - Alice Nicoleta Azoicăi
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
- "Sf. Maria" Children Emergency Hospital, 700309 Iasi, Romania
| | - Felicia Trofin
- Department of Preventive Medicine and Interdisciplinarity-Microbiology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
| | - Alina Mariela Murgu
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
- "Sf. Maria" Children Emergency Hospital, 700309 Iasi, Romania
| | - Dana Elena Mîndru
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
- "Sf. Maria" Children Emergency Hospital, 700309 Iasi, Romania
| | - Ana Simona Bocec
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaṣi, Romania
| | | | - Gabriela Rusu Zota
- Department of Pharmacology, Clinical Pharmacology and Algesiology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Diana Păduraru
- "Dr. C. I. Parhon" Clinical Hospital, 700503 Iaṣi, Romania
| | - Eduard Vasile Nastase
- Department of Internal Medicine II-Infectious Diseases, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Clinical Hospital of Infectious Diseases "Sf. Parascheva", 700116 Iasi, Romania
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Hermie L, Biervliet SV, Hoorens A, Cauwenberghe LV, Robberecht E, Defreyne L. Pre-emptive transjugular intrahepatic portosystemic shunt in pediatric cystic fibrosis-related liver disease and portal hypertension: prospective long-term results. Diagn Interv Radiol 2024; 30:55-64. [PMID: 36994654 PMCID: PMC10773179 DOI: 10.4274/dir.2022.221818] [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: 08/22/2022] [Accepted: 12/23/2022] [Indexed: 03/31/2023]
Abstract
PURPOSE Portal hypertension (PHT) and its sequelae are the most clinically important manifestations in cystic fibrosis-related liver disease (CFLD). This paper aimed to evaluate the safety and efficacy of a pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) to prevent PHT-related complications in pediatric patients with CFLD. METHODS This was a prospective single-arm study on pediatric patients with CFLD, signs of PHT, and preserved liver function who underwent a pre-emptive TIPS in a single tertiary CF center between 2007 and 2012. The long-term safety and clinical efficacy were assessed. RESULTS A pre-emptive TIPS was performed on seven patients with a mean age of 9.2 years (± standard deviation: 2.2). The procedure was technically successful in all patients, with an estimated median primary patency of 10.7 years [interquartile range (IQR) 0.5-10.7)]. No variceal bleeding was observed during the median follow-up of 9 years (IQR 8.1-12.9). In two patients with advanced PHT and rapidly progressive liver disease, severe thrombocytopenia could not be stopped. Subsequent liver transplantation revealed biliary cirrhosis in both patients. In the remaining patients with early PHT and milder porto-sinusoidal vascular disease, symptomatic hypersplenism did not occur, and liver function remained stable until the end of the follow-up. Inclusion for pre-emptive TIPS was discontinued in 2013 following an episode of severe hepatic encephalopathy. CONCLUSION TIPS is a feasible treatment with encouraging long-term primary patency to avoid variceal bleeding in selected patients with CF and PHT. However, as the progression of liver fibrosis, thrombocytopenia, and splenomegaly is inevitable, the clinical benefits due to pre-emptive placement appear to be minor.
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Affiliation(s)
- Laurens Hermie
- Ghent University Hospital, Department of Vascular and Interventional Radiology, Gent, Belgium
| | | | - Anne Hoorens
- Ghent University Hospital, Department of Pathology, Gent, Belgium
| | - Lien Van Cauwenberghe
- Ghent University Hospital, Department of Vascular and Interventional Radiology, Gent, Belgium
| | - Eddy Robberecht
- Ghent University Hospital, Department of Pediatrics, Gent, Belgium
| | - Luc Defreyne
- Ghent University Hospital, Department of Vascular and Interventional Radiology, Gent, Belgium
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Bodewes FAJA, Freeman AJ, Weymann A, Debray D, Scheers I, Verkade HJ, Narkewicz MR. Towards a Standardized Classification of the Hepatobiliary Manifestations in Cystic Fibrosis (CFHBI): A Joint ESPGHAN/NASPGHAN Position Paper. J Pediatr Gastroenterol Nutr 2024; 78:153-165. [PMID: 38291686 DOI: 10.1097/mpg.0000000000003944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/08/2023] [Indexed: 02/01/2024]
Abstract
The broad spectrum of hepatobiliary involvement in cystic fibrosis (CF) has been commonly referred to as cystic fibrosis liver disease (CFLD). However, differences in the definitions of CFLD have led to variations in reported prevalence, incidence rates, and standardized recommendations for diagnosis and therapies. Harmonizing the description of the spectrum of hepatobiliary involvement in all people with CF (pwCF) is deemed essential for providing a reliable account of the natural history, which in turn supports the development of meaningful clinical outcomes in patient care and research. Recognizing this necessity, The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) commissioned and tasked a committee to develop and propose a systematic classification of the CF hepatobiliary manifestations to increase uniformity, accuracy, and comparability for clinical, registry, and research purposes. This report describes the committee's combined expert position statement on hepatobiliary involvement in CF, which has been endorsed by NASPGHAN and ESPGHAN. We recommend using CFHBI (Cystic Fibrosis Hepato-Biliary Involvement) as the updated term to describe and classify all hepatobiliary manifestations in all pwCF. CFHBI encompasses the current extensive spectrum of phenotypical, clinical, or diagnostic expressions of liver involvement observed in pwCF. We present a schematic categorization of CFHBI, which may also be used to track and classify the changes and development of CFHBI in pwCF over time. The proposed classification for CFHBI is based on expert consensus and has not been validated for clinical practice and research purposes. Achieving validation should be an important aim for future research.
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Affiliation(s)
- Frank A J A Bodewes
- Division of Pediatric Gastroenterology/Hepatology, Beatrix Children's Hospital/University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Alvin Jay Freeman
- Division of Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Alexander Weymann
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH
| | - Dominique Debray
- Pediatric Hepatology Unit, Assistance Publique-Hôpitaux de Paris (APHP)-Hôpital Necker-Enfants maladies, Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Paris, France
| | - Isabelle Scheers
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Henkjan J Verkade
- Division of Pediatric Gastroenterology/Hepatology, Beatrix Children's Hospital/University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Michael R Narkewicz
- Digestive Health Institute, Children's Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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6
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Rowland M, Drummond J, Connolly L, Daly E, McCormick PA, Bourke B. The natural history of cystic fibrosis liver disease a prospective cohort study. J Cyst Fibros 2023; 22:1054-1061. [PMID: 37495468 DOI: 10.1016/j.jcf.2023.07.002] [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: 10/28/2022] [Revised: 05/15/2023] [Accepted: 07/05/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Our understanding of the natural history of cystic fibrosis liver disease (CFLD) is limited, leading to uncertainty for patients their families and clinicians when liver abnormalities are identified. AIM to determine the incidence of CFLD, identify risk factors and document the natural history of liver abnormalities in cystic fibrosis (CF). METHODS The Irish longitudinal study of CFLD (ILSCFLD) prospectively enrolled 95% of children with CF in 2007. Their liver disease status was classified as (i) advanced liver disease with portal hypertension (CFLD). (ii) nonspecific cystic fibrosis liver disease (NSCFLD) (iii) no liver disease (NoLD) RESULTS: 480/522 (91.9%) children were followed for a median 8.53 years IQR 1.28, of whom 35 (7.29%) had CFLD, 110 (22.9%) NSCFLD and 335 (69.79%) had NoLD. At follow-up 28/445 (6.29%) participants without CFLD at baseline, progressed to CFLD (Incidence 7.51/1000 person years (Pyrs) (95%CI 4.99-10.86). Of these 25/28(89.28%) were <10 years. No participant >10 years of age without clinical or radiological evidence of liver disease at baseline progressed to CFLD. During follow-up 18/35(51.43%) participants with CFLD died or received a transplant, MTx rate 7.75/100 Pyrs (95%CI 4.59-12.25) compared to NSCFLD 2.33/100 Pyrs (95%CI 1.44-3.56) and NoLD 1.13/100 Pyrs (95%CI 0.77-1.59). CFLD was an independent risk factor for mortality in CF. Children with CFLD also had a shorter life expectancy. CONCLUSION The incidence of CFLD was highest in children under10 years. Children over10 years, with normal hepatic function did not develop CFLD. Research to identify the cause and improve outcome should focus on young children.
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Affiliation(s)
- Marion Rowland
- School of Medicine, University College Dublin, Belfield Dublin 4, Ireland; Catherine McAuley Research Centre, Nelson Street, Dublin 7, Ireland.
| | - Jennifer Drummond
- School of Medicine, University College Dublin, Belfield Dublin 4, Ireland; Catherine McAuley Research Centre, Nelson Street, Dublin 7, Ireland
| | - Lucy Connolly
- School of Medicine, University College Dublin, Belfield Dublin 4, Ireland; Catherine McAuley Research Centre, Nelson Street, Dublin 7, Ireland
| | | | - P Aiden McCormick
- School of Medicine, University College Dublin, Belfield Dublin 4, Ireland; St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Billy Bourke
- School of Medicine, University College Dublin, Belfield Dublin 4, Ireland; Children's Health Ireland at Crumlin, Crumlin Dublin 12, Ireland; National Children's Research Centre, Crumlin Dublin 12, Ireland; Conway Institute of Biomedical and Molecular Science, University College Dublin Belfield, Dublin 4, Ireland
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Towbin AJ, Ye W, Huang S, Karmazyn BW, Molleston JP, Masand P, Leung DH, Chang S, Narkewicz MR, Alazraki AL, Freeman AJ, Otto RK, Green N, Kamel IR, Karnsakul WW, Magee JC, Tkach J, Palermo JJ. Prospective study of quantitative liver MRI in cystic fibrosis: feasibility and comparison to PUSH cohort ultrasound. Pediatr Radiol 2023; 53:2210-2220. [PMID: 37500799 DOI: 10.1007/s00247-023-05706-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 06/08/2023] [Accepted: 06/17/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Pediatric radiologists can identify a liver ultrasound (US) pattern predictive of progression to advanced liver disease. However, reliably discriminating these US patterns remains difficult. Quantitative magnetic resonance imaging (MRI) may provide an objective measure of liver disease in cystic fibrosis (CF). OBJECTIVE The purpose of this study was to determine if quantitative MRI, including MR elastography, is feasible in children with CF and to determine how quantitative MRI-derived metrics compared to a research US. MATERIALS AND METHODS A prospective, multi-institutional trial was performed evaluating CF participants who underwent a standardized MRI. At central review, liver stiffness, fat fraction, liver volume, and spleen volume were obtained. Participants whose MRI was performed within 1 year of US were classified by US pattern as normal, homogeneous hyperechoic, heterogeneous, or nodular. Each MRI measure was compared among US grade groups using the Kruskal-Wallis test. RESULTS Ninety-three participants (51 females [54.8%]; mean 15.6 years [range 8.1-21.7 years]) underwent MRI. MR elastography was feasible in 87 participants (93.5%). Fifty-eight participants had an US within 1 year of MRI. In these participants, a nodular liver had significantly higher stiffness (P<0.01) than normal or homogeneous hyperechoic livers. Participants with a homogeneous hyperechoic liver had a higher fat fraction (P<0.005) than others. CONCLUSION MR elastography is feasible in children with CF. Participants with a nodular pattern had higher liver stiffness supporting the US determination of advanced liver disease. Participants with a homogeneous hyperechoic pattern had higher fat fractions supporting the diagnosis of steatosis.
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Affiliation(s)
- Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital, 3333 Burnet Avenue, MLC 5031, Cincinnati, OH, 45229, USA.
- Department of Radiology, University of Cincinnati School of Medicine, Cincinnati, OH, USA.
| | - Wen Ye
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Suiyuan Huang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Boaz W Karmazyn
- Pediatric Radiology, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Prakash Masand
- Division of Radiology, Texas Children's Hospital, Houston, TX, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's, Baylor College of Medicine, Houston, TX, USA
| | - Samuel Chang
- Department of Radiology, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - Michael R Narkewicz
- Digestive Health Institute, Children's Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adina L Alazraki
- Department of Radiology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Randolph K Otto
- Department of Radiology, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Nicole Green
- Division of Gastroenterology and Hepatology, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Ihab R Kamel
- Department of Radiology, John Hopkins School of Medicine, Baltimore, MD, USA
| | - Wikrom W Karnsakul
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, John Hopkins School of Medicine, Baltimore, MD, USA
| | - John C Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jean Tkach
- Department of Radiology, Cincinnati Children's Hospital, 3333 Burnet Avenue, MLC 5031, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Joseph J Palermo
- Division of Pediatric, Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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8
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Siegel MJ, Leung DH, Molleston JP, Ye W, Paranjape SM, Freeman AJ, Palermo JJ, Stoll J, Masand P, Karmazyn B, Harned R, Ling SC, Navarro OM, Karnsakul W, Alazraki A, Schwarzenberg SJ, Towbin AJ, Alonso EM, Nicholas JL, Green N, Otto RK, Magee JC, Narkewicz MR. Heterogeneous liver on research ultrasound identifies children with cystic fibrosis at high risk of advanced liver disease. J Cyst Fibros 2023; 22:745-755. [PMID: 37032248 PMCID: PMC10523874 DOI: 10.1016/j.jcf.2023.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND This study examines whether heterogeneous (HTG) pattern on liver ultrasound (US) identifies children at risk for advanced cystic fibrosis liver disease (aCFLD). METHODS Prospective 6-year multicenter case-controlled cohort study. Children with pancreatic insufficient cystic fibrosis (CF) aged 3-12 years without known cirrhosis underwent screening US. Participants with HTG were matched (by age, Pseudomonas infection status and center) 1:2 with participants with normal (NL) US pattern. Clinical status and laboratory data were obtained annually and US bi-annually for 6 years. Primary endpoint was development of nodular (NOD) US pattern consistent with aCFLD. RESULTS 722 participants underwent screening US, with 65 HTG and 592 NL. Final cohort included 55 HTG and 116 NL with ≥ 1 follow-up US. ALT, AST, GGTP, FIB-4, GPR and APRI were higher, and platelets were lower in HTG compared to NL. HTG had a 9.5-fold increased incidence (95% confidence interval [CI]:3.4, 26.7, p<0.0001, 32.7% vs 3.4%) of NOD versus NL. HTG had a sensitivity of 82% and specificity of 75% for subsequent NOD. Negative predictive value of a NL US for subsequent NOD was 96%. Multivariate logistic prediction model that included baseline US, age, and log(GPR) improved the C-index to 0.90 compared to only baseline US (C-index 0.78). Based on survival analysis, 50% of HTG develop NOD after 8 years. CONCLUSIONS Research US finding of HTG identifies children with CF with a 30-50% risk for aCFLD. A score based on US pattern, age and GPR may refine the identification of individuals at high risk for aCFLD. CLINICAL TRIAL REGISTRATION Prospective Study of Ultrasound to Predict Hepatic Cirrhosis in CF: NCT 01,144,507 (observational study, no consort checklist).
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Affiliation(s)
- Marilyn J Siegel
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston TX, USA
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Wen Ye
- Department of Biostatistics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Shruti M Paranjape
- Division of Pediatric Pulmonology, John Hopkins School of Medicine, Baltimore, MD, USA
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Atlanta, GA, USA
| | - Joseph J Palermo
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Janis Stoll
- Division of Gastroenterology and Nutrition, Washington University School of Medicine, St Louis, MO, USA
| | - Prakash Masand
- Division of Radiology, Texas Children's Hospital, Houston, TX, USA
| | - Boaz Karmazyn
- Pediatric Radiology, Riley Hospital for Children, Indianapolis, IN, USA
| | - Roger Harned
- Division of Pediatric Radiology, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Simon C Ling
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Oscar M Navarro
- Department of Medical Imaging, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, John Hopkins School of Medicine, Baltimore, MD, USA
| | - Adina Alazraki
- Department of Radiology, Emory University School of Medicine and Children's Healthcare of Atlanta, Egleston, Atlanta, GA, USA
| | - Sarah Jane Schwarzenberg
- Pediatric Gastroenterology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Alex J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center and Department of Radiology, University of Cincinnati College of Medicine Cincinnati, OH, USA
| | - Estella M Alonso
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Jennifer L Nicholas
- Department of Radiology, Case Western Reserve School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Nicole Green
- Division of Gastroenterology and Hepatology, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Randolph K Otto
- Department of Radiology, Seattle Children's Hospital, Seattle, WA, USA
| | - John C Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael R Narkewicz
- Children's Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Digestive Health Institute, University of Colorado School of Medicine, Aurora, CO, USA.
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9
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Vélez C, Freedman SD, Assis DN. Update in Advancing the Gastrointestinal Frontier in Cystic Fibrosis. Clin Chest Med 2022; 43:743-755. [PMID: 36344078 DOI: 10.1016/j.ccm.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Clinical complications of cystic fibrosis (CF) include a variety of gastrointestinal (GI) and hepatobiliary manifestations. Recent years have witnessed several advances in the understanding and management of these complications, in addition to opportunities for therapeutic innovations. Herein we review the current understanding of these disorders and also discuss the management of the GI and hepatobiliary complications experienced by persons with CF.
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Affiliation(s)
- Christopher Vélez
- Division of Gastroenterology, Department of Medicine, Center for Neurointestinal Health, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street Suite 535, Boston, MA 0211, USA
| | - Steven D Freedman
- Beth Israel Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - David N Assis
- Section of Digestive Diseases, Yale School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06510, USA.
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10
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Schwarzenberg SJ, Palermo JJ, Ye W, Huang S, Magee JC, Alazraki A, Jay Freeman A, Harned R, Karmazyn B, Karnsakul W, Leung DH, Ling SC, Masand P, Molleston JP, Murray KF, Navarro OM, Nicholas JL, Otto RK, Paranjape SM, Siegel MJ, Stoll J, Towbin AJ, Narkewicz MR, Alonso EM. Health-related Quality of Life in a Prospective Study of Ultrasound to Detect Cystic Fibrosis-related Liver Disease in Children. J Pediatr Gastroenterol Nutr 2022; 75:635-642. [PMID: 36070552 PMCID: PMC9624376 DOI: 10.1097/mpg.0000000000003605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Cystic fibrosis liver disease (CFLD) begins early in life. Symptoms may be vague, mild, or nonexistent. Progressive liver injury may be associated with decrements in patient health before liver disease is clinically apparent. We examined Health-Related Quality of Life (HRQOL) in children enrolled in a multi-center study of CFLD to determine the impact of early CFLD on general and disease-specific QOL. METHODS Ultrasound (US) patterns of normal (NL), heterogeneous (HTG), homogeneous (HMG), or nodular (NOD) were assigned in a prospective manner to predict those at risk for advanced CFLD. Parents were informed of results. We assessed parent/child-reported (age ≥5 years) HRQOL by PedsQL 4.0 Generic Core and CF Questionnaire-revised (CFQ-R) prior to US and annually. HRQOL scores were compared by US pattern at baseline (prior to US), between baseline and 1 year and at 5 years. Multivariate analysis of variance (MANOVA) with Hotelling-Lawley trace tested for differences among US groups. RESULTS Prior to US, among 515 participants and their parents there was no evidence that HTG or NOD US was associated with reduced PedsQL/CFQ-R at baseline. Parents of NOD reported no change in PedsQL/CFQ-R over the next year. Child-report PedsQL/CFQ-R (95 NL, 20 NOD) showed improvement between baseline and year 5 for many scales, including Physical Function. Parents of HMG children reported improved CFQ-R scores related to weight. CONCLUSIONS Early undiagnosed or pre-symptomatic liver disease had no impact on generic or disease-specific HRQoL, and HRQoL was remarkably stable in children with CF regardless of liver involvement.
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Affiliation(s)
- Sarah Jane Schwarzenberg
- Pediatric Gastroenterology, Hepatology and Nutrition, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN
| | - Joseph J. Palermo
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Wen Ye
- Department of Biostatistics, University of Michigan Medical School, Ann Arbor, MI
| | - Suiyuan Huang
- Department of Biostatistics, University of Michigan Medical School, Ann Arbor, MI
| | - John C. Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Adina Alazraki
- Department of Radiology, Emory University School of Medicine and Children’s Healthcare of Atlanta, Egleston, Atlanta, GA
| | - A. Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, and Children’s Healthcare of Atlanta, Atlanta, GA
| | - Roger Harned
- Division of Pediatric Radiology, Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | - Boaz Karmazyn
- Pediatric Radiology, Riley Hospital for Children, Indianapolis, IN
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, John Hopkins School of Medicine, Baltimore, MD
| | - Daniel H. Leung
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children’s Hospital, Houston TX
| | - Simon C. Ling
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Prakash Masand
- Division Radiology, Texas Children’s Hospital, Houston TX
| | - Jean P. Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Karen F. Murray
- Pediatric Institute, Cleveland Clinic and Cleveland Clinic Children’s, Cleveland, OH
| | - Oscar M. Navarro
- Department of Medical Imaging, University of Toronto and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jennifer L. Nicholas
- Division of Pediatric Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine
| | - Randolph K. Otto
- Department of Radiology, Seattle Children’s Hospital, Seattle, WA
| | - Shruti M. Paranjape
- Division of Pediatric Pulmonology, John Hopkins School of Medicine, Baltimore, MD
| | - Marilyn J. Siegel
- Division of Pediatric Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine
| | - Janis Stoll
- Division of Gastroenterology and Nutrition, Washington University School of Medicine, St Louis, MO
| | - Alexander J. Towbin
- Department of Radiology, Cincinnati Children’s Hospital Medical Center and Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Michael R. Narkewicz
- Digestive Health Institute, Children’s Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Estella M. Alonso
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children’s Hospital, Chicago, IL
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11
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Leung DH, Ye W, Schwarzenberg SJ, Freeman AJ, Palermo JJ, Weymann A, Alonso EM, Karnsakul WW, Murray KF, Stoll JM, Huang S, Karmazyn B, Masand P, Magee JC, Alazraki AL, Towbin AJ, Nicholas JL, Green N, Otto RK, Siegel MJ, Ling SC, Navarro OM, Harned RK, Narkewicz MR, Molleston JP. Long-term follow-up and liver outcomes in children with cystic fibrosis and nodular liver on ultrasound in a multi-center study. J Cyst Fibros 2022; 22:248-255. [PMID: 35985930 DOI: 10.1016/j.jcf.2022.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/30/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Nodular liver (NOD) in cystic fibrosis (CF) suggests advanced CF liver disease (aCFLD); little is known about progression of liver disease (LD) after detection of sonographic NOD. METHODS Clinical, laboratory, and ultrasound (US) data from Prediction by Ultrasound of the Risk of Hepatic Cirrhosis in CFLD Study participants with NOD at screening or follow-up were compared with normal (NL). Linear mixed effects models were used for risk factors for LD progression and Kaplan-Meier estimator for time-to-event. RESULTS 54 children with NOD (22 screening, 32 follow-up) and 112 NL were evaluated. Baseline (BL) and trajectory of forced expiratory volume, forced vital capacity, height/BMI z-scores were similar in NOD vs NL. Platelets were lower in NOD at BL (250 vs 331×103/microL; p < 0.001) and decreased by 8600/year vs 2500 in NL. Mean AST to Platelet Ratio Index (1.1 vs 0.4; p < 0.001), Fibrosis-4 Index (0.4 vs 0.2, p < 0.001), and spleen size z-score (SSZ) [1.5 vs 0.02; p < 0.001] were higher in NOD at BL; SSZ increased by 0.5 unit/year in NOD vs 0.1 unit/year in NL. Median liver stiffness (LSM) by transient elastography was higher in NOD (8.2 kPa, IQR 6-11.8) vs NL (5.3, 4.2-7, p < 0.0001). Over 6.3 years follow-up (1.3-10.3), 6 NOD had esophageal varices (cumulative incidence in 10 years: 20%; 95% CI: 0.0%, 40.0%), 2 had variceal bleeding, and 2 underwent liver transplantation; none had ascites or hepatic encephalopathy. No NL experienced liver-related events. CONCLUSIONS NOD developed clinically evident portal hypertension faster than NL without worse growth or lung disease.
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Key Words
- ALT, alanine aminotransferase
- APRI, aspartate aminotransferase to platelet ratio index
- AST, aminotransferase
- CAP, continuous attenuation parameter
- CFRD, cystic-fibrosis-related diabetes
- CFTR, cystic fibrosis transmembrane regulator
- Cirrhosis
- Cystic fibrosis liver disease
- FEV1, forced expiratory volume in one second
- FIB4, fibrosis index based on four factors
- FVC, forced vital capacity
- GGT, gamma-glutamyl transferase
- IGT, impaired glucose tolerance
- INR, international normalized ratio
- LSM, liver stiffness measurement
- NL, normal
- NOD, nodular
- PELD, pediatric end-stage liver disease
- PUSH, prediction by ultrasound of the risk of hepatic cirrhosis
- US, ultrasound
- Ultrasound
- VCTE, vibration controlled transient elastography
- WBC, white blood cell count
- abbreviations: CF, cystic fibrosis
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Affiliation(s)
- Daniel H Leung
- Department of Pediatrics, Baylor College of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, 6621 Fannin St, CCC 1010.00, Houston, TX 77030, USA
| | - Wen Ye
- Department of Biostatistics, University of Michigan, 1420 Washington Heights, M4073 SPH II, Ann Arbor, MI 48109, USA
| | - Sarah J Schwarzenberg
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Minnesota, 2450 Riverside Save S AO-201, Minneapolis, MN 55454, USA
| | - A Jay Freeman
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University, 2015 Uppergate Drive, NE, Atlanta, GA 30322, USA
| | - Joseph J Palermo
- Department of Pediatrics, Division of Gastroenterology, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 2010, Cincinnati, OH 45229, USA
| | - Alexander Weymann
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA
| | - Estella M Alonso
- Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Northwestern University Feinberg School of Medicine, 225 E. Chicago Avenue, Box 57, Chicago, IL 60611, USA
| | - Wikrom W Karnsakul
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, 600 N Wolfe Street, CMSC-2, Baltimore, MD 21287, USA
| | - Karen F Murray
- Pediatric Institute and Cleveland Clinic Children's, Cleveland Clinic, 8950 Euclid Avenue, R3, Cleveland, OH 44195, USA
| | - Janis M Stoll
- Department of Pediatrics, Division of Gastroenterology, Pediatric Hepatology and Nutrition, Washington University School of Medicine in St. Louis, One Children's Place, Suite 8116, St. Louis, MO 63110, USA
| | - Suiyuan Huang
- Department of Biostatistics, University of Michigan, 1420 Washington Heights, M4073 SPH II, Ann Arbor, MI 48109, USA
| | - Boaz Karmazyn
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N. University Blvd, Rm 0663, Indianapolis, IN 46202, USA
| | - Prakash Masand
- Department of Pediatrics, Baylor College of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, 6621 Fannin St, CCC 1010.00, Houston, TX 77030, USA
| | - John C Magee
- Department of Surgery, University of Michigan School of Medicine, 1500 E Medical Center Drive, UH South Rm 6689, Ann Arbor, MI 48109, USA
| | - Adina L Alazraki
- Department of Radiology, Children's Healthcare of Atlanta, Emory University, 1405 Clifton Rd NE, Atlanta, GA 30322, USA
| | - Alexander J Towbin
- Department of Radiology, University of Cincinnati College of Medicine, 234 Goodman Street, PO Box 670761, Cincinnati, OH 45267, USA
| | - Jennifer L Nicholas
- Department of Radiology, Division of Pediatric Imaging, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Nicole Green
- Department of Pediatrics, Division of Gastroenterology and Hepatology, Seattle Children's Hospital, 4800 Sand Point Way NE, PO Box 5371, Seattle, WA 98105, USA
| | - Randolph K Otto
- Department of Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, MA.7.220, Seattle, WA 98105, USA
| | - Marilyn J Siegel
- Edward Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Blvd, St. Louis, MO 63110, USA
| | - Simon C Ling
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, University of Toronto, 555 University Ave ON, Toronto, M5G 1X8, Canada
| | - Oscar M Navarro
- Department of Diagnostic Imaging, Division of Pediatric Imaging, University of Toronto, 263 McCaul St 4th floor, Toronto, ON M5T 1W7, Canada
| | - Roger K Harned
- Department of Radiology-Diagnostics, University of Colorado School of Medicine, 13123 East 16th Avenue, B125, Aurora, CO 80045, USA
| | - Michael R Narkewicz
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B290, Aurora, CO 80045, USA
| | - Jean P Molleston
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children at IU Health, Indiana University School of Medicine, 705 Riley Hospital Drive, ROC 4210, Indianapolis, IN 46202, USA.
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12
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Sherwood JS, Ullal J, Kutney K, Hughan KS. Cystic fibrosis related liver disease and endocrine considerations. J Clin Transl Endocrinol 2022; 27:100283. [PMID: 35024343 PMCID: PMC8724940 DOI: 10.1016/j.jcte.2021.100283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/23/2021] [Accepted: 11/27/2021] [Indexed: 12/12/2022] Open
Abstract
Cystic fibrosis-liver disease (CFLD) is one of the most common non-pulmonary complications in the CF population, is associated with significant morbidity and represents the third leading cause of mortality in those with CF. CFLD encompasses a broad spectrum of hepatobiliary manifestations ranging from mild transaminitis, biliary disease, hepatic steatosis, focal biliary cirrhosis and multilobular biliary cirrhosis. The diagnosis of CFLD and prediction of disease progression remains a clinical challenge. The identification of novel CFLD biomarkers as well as the role of newer imaging techniques such as elastography to allow for early detection and intervention are active areas of research focus. Biliary cirrhosis with portal hypertension represents the most severe spectrum of CFLD, almost exclusively develops in the pediatric population, and is associated with a decline in pulmonary function, poor nutritional status, and greater risk of hospitalization. Furthermore, those with CFLD are at increased risk for vitamin deficiencies and endocrinopathies including CF-related diabetes, CF-related bone disease and hypogonadism, which can have further implications on disease outcomes and management. Effective treatment for CFLD remains limited and current interventions focus on optimization of nutritional status, identification and treatment of comorbid conditions, as well as early detection and management of CFLD specific sequelae such as portal hypertension or variceal bleeding. The extent to which highly effective modulator therapies may prevent the development or modify the progression of CFLD remains an active area of research. In this review, we discuss the challenges with defining and evaluating CFLD and the endocrine considerations and current management of CFLD.
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Key Words
- APRI, aspartate aminotransferase to platelet ratio
- BMI, body mass index
- CFBD, CF bone disease
- CFLD, Cystic fibrosis-liver disease
- CFRD, CF related diabetes
- CFTR, cystic fibrosis transmembrane conductance regulator
- Cirrhosis
- Cystic fibrosis liver disease
- Cystic fibrosis-related diabetes
- FFA, free fatty acids
- Fib-4, Fibrosis-4
- GH, growth hormone
- IGF-1, insulin-like growth factor-1
- Insulin resistance
- UDCA, ursodeoxycholic acid
- ULN, upper limit of normal
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Affiliation(s)
- Jordan S. Sherwood
- Department of Pediatrics, Diabetes Research Center, Division of Pediatric Endocrinology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Jagdeesh Ullal
- Department of Medicine, UPMC Center for Diabetes and Endocrinology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Katherine Kutney
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Kara S. Hughan
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, United States
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13
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Dana J, Girard M, Franchi-Abella S, Berteloot L, Benoit-Cherifi M, Imbert-Bismut F, Sermet-Gaudelus I, Debray D. Comparison of Transient Elastography, ShearWave Elastography, Magnetic Resonance Elastography and FibroTest as routine diagnostic markers for assessing liver fibrosis in children with Cystic Fibrosis. Clin Res Hepatol Gastroenterol 2022; 46:101855. [PMID: 34933150 DOI: 10.1016/j.clinre.2021.101855] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/10/2021] [Accepted: 12/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Reliable markers are needed for early diagnosis and follow-up of liver disease in Cystic Fibrosis (CF). The objective was to evaluate the diagnostic performance of Transient Elastography (TE), Real-Time ShearWave Ultrasound Elastography (SWE), Magnetic Resonance Elastography (MRE) and the FibroTest as markers of Cystic Fibrosis Liver Disease (CFLD). METHODS A monocentric prospective cross-modality comparison study was proposed to all children (6 to 18 years of age) attending the CF center. Based on liver ultrasound findings, participants were classified into 3 groups: multinodular liver or portal hypertension (Nodular US/PH, advanced CFLD), heterogeneous increased echogenicity (Heterogeneous US, CFLD) or neither (Normal/Homogeneous US, no CFLD). The 4 tests were performed on the same day. The primary outcome was the FibroTest value and liver stiffness measurements (LSM). RESULTS 55 participants (mean age 12.6 ± 3.3 years; 25 girls) were included between 2015 and 2018: 23 in group Nodular US/PH, 8 in group Heterogeneous US and 24 in group Normal/Homogeneous US (including 4 with steatosis). LSM on TE, SWE and MRE were higher in participants with CFLD (groups Nodular US/PH and Heterogeneous US) compared to others (group Normal/Homogeneous US) (p<0.01), while FibroTest values did not differ (p = 0.09). The optimal cut-off values for predicting CFLD on TE, SWE and MRE were 8.7 (AUC=0.83, Se=0.71, Sp=0.96), 7.8 (AUC=0.85, Se=0.73, Sp=0.96) and 4.15 kPa (AUC=0.68, Se=0.73, Sp=0.64), respectively. LSM predicted the occurrence of major liver-related events at 3 years. TE and SWE were highly correlated (Spearman's ρ=0.9) and concordant in identifying advanced CFLD (Cohen's κ=0.84) while MRE was moderately correlated and concordant with TE (ρ=0.41; κ=36) and SWE (ρ=0.5; κ=0.50). CONCLUSION This study demonstrated excellent diagnostic performance of TE, SWE and MRE for the diagnosis of CFLD.
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Affiliation(s)
- Jérémy Dana
- Department of Pediatric Radiology, Hôpital Necker-Enfants Malades, AP-HP, Paris, France; IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France; Institut National de la Santé et de la Recherche Médicale (Inserm), U1110, Institut de Recherche sur les Maladies Virales et Hépatiques, Strasbourg, France.
| | - Muriel Girard
- Pediatric Hepatology unit, Centre de Référence Maladies Rares (CRMR) de l'atrésie des voies biliaires et cholestases génétiques (AVB-CG), National network for rare liver diseases (Filfoie), ERN rare liver, Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, Paris, France; Inserm U1151, Institut Necker-Enfants Malades, Paris, France
| | - Stéphanie Franchi-Abella
- Department of Pediatric Radiology, APHP-Bicêtre Hospital, UMR BioMaps Paris-Saclay, Paris Saclay University, Kremlin-Bicêtre, France
| | - Laureline Berteloot
- Department of Pediatric Radiology, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | | | - Françoise Imbert-Bismut
- Department of Metabolic Biochemistry, Hôpital Pitié Salpétrière Charlefoix, AP-HP, Paris, France; Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Isabelle Sermet-Gaudelus
- Centre de Référence Maladies Rares (CRMR), Mucoviscidose et maladies de CFTR, European Respiratory Network Lung, Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, Paris, France; Inserm U1121, Necker-Enfants Malades Institute, Paris, France
| | - Dominique Debray
- Pediatric Hepatology unit, Centre de Référence Maladies Rares (CRMR) de l'atrésie des voies biliaires et cholestases génétiques (AVB-CG), National network for rare liver diseases (Filfoie), ERN rare liver, Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, Paris, France; Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
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14
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Cystic fibrosis-related liver disease: Clinical presentations, diagnostic and monitoring approaches in the era of CFTR modulator therapies. J Hepatol 2022; 76:420-434. [PMID: 34678405 DOI: 10.1016/j.jhep.2021.09.042] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/09/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022]
Abstract
Cystic fibrosis (CF) is the most common autosomal recessive disease in the Caucasian population. Cystic fibrosis-related liver disease (CFLD) is defined as the pathogenesis related to the underlying CFTR defect in biliary epithelial cells. CFLD needs to be distinguished from other liver manifestations that may not have any pathological significance. The clinical/histological presentation and severity of CFLD vary. The main histological presentation of CFLD is focal biliary fibrosis, which is usually asymptomatic. Portal hypertension develops in a minority of cases (about 10%) and may require specific management including liver transplantation for end-stage liver disease. Portal hypertension is usually the result of the progression of focal biliary fibrosis to multilobular cirrhosis during childhood. Nevertheless, non-cirrhotic portal hypertension as a result of porto-sinusoidal vascular disease is now identified increasingly more frequently, mainly in young adults. To evaluate the effect of new CFTR modulator therapies on the liver, the spectrum of hepatobiliary involvement must first be precisely classified. This paper discusses the phenotypic features of CFLD, its underlying physiopathology and relevant diagnostic and follow-up approaches, with a special focus on imaging.
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15
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Yang HT, Xiu WJ, Liu JK, Yang Y, Zhang YJ, Zheng YY, Wu TT, Hou XG, Wu CX, Ma YT, Xie X. Characteristics of the Intestinal Microorganisms in Middle-Aged and Elderly Patients: Effects of Smoking. ACS OMEGA 2022; 7:1628-1638. [PMID: 35071858 PMCID: PMC8771693 DOI: 10.1021/acsomega.1c02120] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/21/2021] [Indexed: 06/14/2023]
Abstract
Introduction: Smoking affects the occurrence and development of many diseases. We attempt to study the structure of intestinal flora in the middle-aged and elderly population as well as how smoking affects the intestinal flora. Methods: We collected population information, biochemical indicators, and patient feces from 188 middle-aged and elderly male patients, and their feces were tested for the 16S rRNA gene of intestinal flora. Results: We performed a cluster analysis on the intestinal structure of the included population and found that there was a significant difference in the number of smokers between each group (p = 0.011). Subsequently, the microbiological diversity analysis of current smokers and nonsmokers was carried out. The results indicated that there was a significant difference in species composition between the two groups (p = 0.029). Through the analysis on LEfSe differential bacteria, it was found that in current smoking patients, the abundances of the genus Bifidobacterium and the genus Coprobacillus were less, while the abundances of the genera Shigella, Paraprevotella, Burkholderia, Sutterella, Megamonas, and p-75-a5 under the family level of Erysipelotrichaceae were slightly high. We analyzed the correlation between the abundances of these eight different bacteria and clinical indicators. The results revealed the following: the abundance of the genus Bifidobacterium was negatively correlated with fasting blood glucose (r = -0.198, p = 0.006) and positively correlated with uric acid (r = 0.207, p = 0.004) and total bilirubin (r = 0.175, p = 0.017); Shigella bacteria were positively correlated with fasting blood glucose (r = 0.160, p = 0.028) and uric acid (r = 0.153, p = 0.036) levels; the genus Paraprevotella and BMI (r = -0.172, p = 0.018) are negatively correlated; the abundance of the genus Burkholderia was positively correlated with γ-glutamyltransferase (r = 0.146, p = 0.045) levels; Sutterella was correlated with fasting blood glucose (r = 0.143, p = 0.05) and creatinine level (r = -0.16, p = 0.027), which was positively correlated with fasting blood glucose and negatively correlated with creatinine. Conclusions: In middle-aged and elderly patients with cardiovascular disease, smoking can reduce the abundance of Bifidobacterium, while the abundances of some negative bacteria such as Burkholderia, Sutterella, and Megamonas increase.
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Affiliation(s)
- Hai-Tao Yang
- Department
of Cardiology, First Affiliated Hospital
of Xinjiang Medical University, Urumqi 830011, China
| | - Wen-Juan Xiu
- Department
of Cardiology, First Affiliated Hospital
of Xinjiang Medical University, Urumqi 830011, China
| | - Jing-Kun Liu
- Department
of Oncology, First Affiliated Hospital of
Xinjiang Medical University, Urumqi 830011, China
| | - Yi Yang
- Department
of Cardiology Fourth Ward, Xinjiang Medical
University Affiliated Hospital of Traditional Chinese Medicine, Urumqi 830011, China
| | - Yan-jun Zhang
- Department
of Clinical Research Center, People’s
Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830000, China
| | - Ying-Ying Zheng
- Department
of Cardiology, First Affiliated Hospital
of Zhengzhou University, Key Laboratory of Cardiac Injury and Repair
of Henan Province, Zhengzhou 450002, China
| | - Ting-Ting Wu
- Department
of Cardiology, First Affiliated Hospital
of Xinjiang Medical University, Urumqi 830011, China
| | - Xian-Geng Hou
- Department
of Cardiology, First Affiliated Hospital
of Xinjiang Medical University, Urumqi 830011, China
| | - Cheng-Xin Wu
- Department
of Cardiology, First Affiliated Hospital
of Xinjiang Medical University, Urumqi 830011, China
| | - Yi-Tong Ma
- Department
of Cardiology, First Affiliated Hospital
of Xinjiang Medical University, Urumqi 830011, China
| | - Xiang Xie
- Department
of Cardiology, First Affiliated Hospital
of Xinjiang Medical University, Urumqi 830011, China
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16
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Valamparampil JJ, Gupte GL. Cystic fibrosis associated liver disease in children. World J Hepatol 2021; 13:1727-1742. [PMID: 34904041 PMCID: PMC8637674 DOI: 10.4254/wjh.v13.i11.1727] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/19/2021] [Accepted: 09/17/2021] [Indexed: 02/06/2023] Open
Abstract
Cystic fibrosis (CF) is an autosomal recessive disorder caused by mutations in the CF transmembrane conductance regulator gene. CF liver disease develops in 5%-10% of patients with CF and is the third leading cause of death among patients with CF after pulmonary disease or lung transplant complications. We review the pathogenesis, clinical presentations, complications, diagnostic evaluation, effect of medical therapies especially CF transmembrane conductance regulator modulators and liver transplantation in CF associated liver disease.
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Affiliation(s)
| | - Girish L Gupte
- Liver Unit, Birmingham Children’s Hospital, Birmingham B4 6NH, United Kingdom
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17
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Abstract
PURPOSE OF REVIEW Liver disease (CFLD) as a complication of cystic fibrosis is recognized as a more severe disease phenotype in both children and adults. We review recent advances in understanding the disease mechanism and consider the implications of new strategies for the diagnosis and management of cystic fibrosis in those with evidence of clinically significant liver disease. RECENT FINDINGS Evidence suggests that the prevalence of CFLD has not declined with the introduction of newborn screening. Furthermore, children with CFLD, who have been diagnosed with cystic fibrosis following newborn screening continue to have a much higher mortality rate compared with those with no liver disease. There is further data suggesting noncirrhotic obliterative portal venopathy as the predominant pathological mechanism in the majority of children and young adults receiving a liver transplantation. Little progress has been made in developing an accurate noninvasive test for early diagnosis or monitoring disease progression in CFLD. The benefit of new modulator therapies is not well understood in those with established CFLD, whereas the risk of hepatotoxicity as a complication of treatment must be carefully monitored. SUMMARY Better understanding of the pathophysiology of CFLD would allow a standardized approach to diagnosis, with the potential to improve outcomes for those with CFLD.
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18
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Sathe M, Sharma PB, Savant AP. Year in review 2020: Nutrition and gastrointestinal disease in cystic fibrosis. Pediatr Pulmonol 2021; 56:3120-3125. [PMID: 34310872 DOI: 10.1002/ppul.25587] [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: 06/03/2021] [Revised: 07/04/2021] [Accepted: 07/07/2021] [Indexed: 11/11/2022]
Abstract
The multisystemic manifestations of cystic fibrosis (CF) involve all parts of the gastrointestinal (GI) system, including the pancreas, intestine, and liver. As providers who care for people with CF, knowledge of the manifestations, treatment, and research related to nutrition and GI disease are important. This review is the last installment of the CF year in review 2020 series, focusing on nutritional, GI, and hepatobiliary articles from Pediatric Pulmonology and other journals of particular interest to clinicians.
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Affiliation(s)
- Meghana Sathe
- Division Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Texas Southwestern and Children's Health, Dallas, Texas, USA
| | - Preeti B Sharma
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, University of Texas Southwestern and Children's Health, Dallas, Texas, USA
| | - Adrienne P Savant
- Division of Pulmonary Medicine, Department of Pediatrics, Tulane University School of Medicine, Children's Hospital of New Orleans, New Orleans, Louisiana, USA
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19
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Sasame A, Stokes D, Bourke B, Connolly L, Fitzpatrick E, Rowland M. The impact of liver disease on mortality in cystic fibrosis-A systematic review. J Cyst Fibros 2021; 21:202-211. [PMID: 34380590 DOI: 10.1016/j.jcf.2021.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/12/2021] [Accepted: 07/24/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND There is conflicting evidence on the impact of liver disease (CFLD) on life expectancy in CF. Therefore the aim of this systematic review was to evaluate the impact of liver disease (CFLD) on mortality in CF. METHODS The protocol was published at (https://hrbopenresearch.org/articles/3-44/v3) using PRISPMA-P guidelines and registered in Prospero 2020 (CRD42020182885). Three databases were searched for publications (1938-2020) where the outcome was all-cause mortality (defined as death and transplantation) or CF-specific mortality in participants with CFLD. Studies with and without a comparator group were included. Studies were divided into 2 groups based on the definition of CFLD: Group 1 used 2 categories of liver disease (i) liver disease with portal hypertension (PH) (ii) non-specific abnormalities which did not meet the criteria for PH, Group 2 studies only included participants with PH. RESULTS All 14 eligible studies were observational, with a moderate-high risk of bias, Six of the 14 studies directly compared mortality between those with CFLD and those with no liver disease, and 5/6 demonstrated that those with CFLD had at least 3 time the risk of death compared to those with no liver disease. Pulmonary complications were the primary cause of death. CONCLUSION This SR demonstrates that liver disease shortens life expectancy in CF, and that pulmonary complications are the primary cause of death in those with CFLD. There has been no improvement in survival for persons with CFLD despite significant improvements in life expectancy for persons with CF who have no evidence of liver disease.
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Affiliation(s)
- Ao Sasame
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland
| | - Diarmuid Stokes
- UCD Library, University College Dublin, Belfield, Dublin 4, Ireland
| | - Billy Bourke
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland; Children's Health Ireland at Crumlin, Crumlin, Dublin 12, Ireland; King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Lucy Connolly
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland
| | - Emer Fitzpatrick
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland; Children's Health Ireland at Crumlin, Crumlin, Dublin 12, Ireland; King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Marion Rowland
- School of Medicine University College Dublin, Belfield, Dublin 4, Ireland.
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20
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Ye W, Leung DH, Molleston JP, Ling SC, Murray KF, Nicholas JL, Huang S, Karmazyn BW, Harned RK, Masand P, Alazraki AL, Navarro OM, Otto RK, Palermo JJ, Towbin AJ, Alonso EM, Karnsakul WW, Jane Schwarzenberg S, Seidel GF, Siegel M, Magee JC, Narkewicz MR, Jay Freeman A. Association Between Transient Elastography and Controlled Attenuated Parameter and Liver Ultrasound in Children With Cystic Fibrosis. Hepatol Commun 2021; 5:1362-1372. [PMID: 34430781 PMCID: PMC8369935 DOI: 10.1002/hep4.1719] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/14/2021] [Accepted: 03/01/2021] [Indexed: 02/04/2023] Open
Abstract
Methods to identify children with cystic fibrosis (CF) at risk for development of advanced liver disease are lacking. We aim to determine the association between liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE) with research ultrasound (US) patterns and conventional hepatic markers as a potential means to follow liver disease progression in children with CF. ELASTIC (Longitudinal Assessment of Transient Elastography in CF) is a nested cohort of 141 patients, ages 7-21, enrolled in the Prediction by US of Risk of Hepatic Cirrhosis in CF (PUSH) Study. We studied the association between LSM with research-grade US patterns (normal [NL], heterogeneous [HTG], homogeneous [HMG], or nodular [NOD]) and conventional hepatic markers. In a subgroup (n = 79), the association between controlled attenuation parameter (CAP) and US pattern was explored. Among 133 subjects undergoing VCTE, NOD participants (n = 26) had a significantly higher median (interquartile range) LSM of 9.1 kPa (6.3, 15.8) versus NL (n = 72, 5.1 kPa [4.2, 7.0]; P < 0.0001), HMG (n = 17, 5.9 kPa [5.2, 7.8]; P = 0.0013), and HTG (n = 18, 6.1 kPa [4.7, 7.0]; P = 0.0008) participants. HMG participants (n = 14) had a significantly higher mean CAP (SD) (270.5 dB/m [61.1]) compared with NL (n = 40, 218.8 dB/m [46.5]; P = 0.0027), HTG (n = 10, 218.1 dB/m [60.7]; P = 0.044), and NOD (n = 15, 222.7 dB/m [56.4]; P = 0.041) participants. LSM had a negative correlation with platelet count (rs = - 0.28, P = 0.0071) and positive correlation with aspartate aminotransferase-to-platelet ratio index (rs = 0.38, P = 0.0002), Fibrosis-4 index (rs = 0.36, P = 0.0007), gamma-glutamyltransferase (GGT; rs = 0.35, P = 0.0017), GGT-to-platelet ratio (rs = 0.35, P = 0.003), and US spleen size z-score (rs = 0.27, P = 0.0073). Conclusion: VCTE is associated with US patterns and conventional markers in patients with liver disease with CF.
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Affiliation(s)
- Wen Ye
- Department of BiostatisticsUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and NutritionDepartment of PediatricsTexas Children's HospitalBaylor College of MedicineHoustonTXUSA
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology and NutritionRiley Hospital for Children at IU HealthIndiana University School of MedicineIndianapolisINUSA
| | - Simon C Ling
- The Hospital for Sick ChildrenDepartment of PediatricsUniversity of TorontoTorontoONCanada
| | - Karen F Murray
- Division of Gastroenterology and HepatologyUniversity of Washington and Seattle Children's HospitalSeattleWAUSA
| | - Jennifer L Nicholas
- Mallinckrodt Institute of RadiologyWashington University School of MedicineSt. LouisMOUSA
| | - Suiyuan Huang
- Department of BiostatisticsUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | - Boaz W Karmazyn
- Pediatric RadiologyRiley Hospital for Children at IU HealthIndiana University School of MedicineIndianapolisINUSA
| | - Roger K Harned
- Division of Pediatric RadiologyChildren's Hospital Colorado and University of Colorado School of MedicineAuroraCOUSA
| | - Prakash Masand
- Division of RadiologyTexas Children's HospitalHoustonTXUSA
| | - Adina L Alazraki
- Department of RadiologyEmory University School of Medicine and Children's Healthcare of AtlantaAtlantaGAUSA
| | - Oscar M Navarro
- Department of Medical ImagingUniversity of TorontoTorontoONCanada.,Department of Diagnostic ImagingThe Hospital for Sick ChildrenTorontoONCanada
| | - Randolph K Otto
- Department of RadiologyUniversity of Washington and Seattle Children's HospitalSeattleWAUSA
| | - Joseph J Palermo
- Division of Pediatric Gastroenterology, Hepatology and NutritionCincinnati Children's Hospital Medical CenterCincinnatiOHUSA.,Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Alexander J Towbin
- Department of RadiologyCincinnati Children's Hospital Medical CenterCincinnatiOHUSA.,Department of RadiologyUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Estella M Alonso
- Division of Pediatric Gastroenterology, Hepatology and NutritionAnn & Robert H. Lurie Children's HospitalChicagoILUSA
| | - Wikrom W Karnsakul
- Division of Pediatric Gastroenterology, Hepatology and NutritionJohn Hopkins School of MedicineBaltimoreMDUSA
| | | | - Glenn F Seidel
- Pediatric RadiologyLucile Packard Children's HospitalPalo AltoCAUSA
| | - Marilyn Siegel
- Mallinckrodt Institute of RadiologyWashington University School of MedicineSt. LouisMOUSA
| | - John C Magee
- Department of SurgeryUniversity of Michigan Medical SchoolAnn ArborMIUSA
| | - Michael R Narkewicz
- Digestive Health InstituteChildren's Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and NutritionDepartment of PediatricsUniversity of Colorado School of MedicineAuroraCOUSA
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and NutritionEmory University School of Medicine/Children's Healthcare of AtlantaAtlantaGAUSA
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21
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Nagamani SCS, Ali S, Izem R, Schady D, Masand P, Shneider BL, Leung DH, Burrage LC. Biomarkers for liver disease in urea cycle disorders. Mol Genet Metab 2021; 133:148-156. [PMID: 33846069 PMCID: PMC8195846 DOI: 10.1016/j.ymgme.2021.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/03/2021] [Accepted: 04/04/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Urea cycle disorders (UCDs) are among the most common inborn errors of liver metabolism. As therapies for hyperammonemia associated with urea cycle dysfunction have improved, chronic complications, such as liver disease, have become increasingly apparent in individuals with UCDs. Liver disease in UCDs may be associated with hepatic inflammation, hepatic fibrosis, portal hypertension, liver cancer and even liver failure. However, except for monitoring serum aminotransferases, there are no clear guidelines for screening and/or monitoring individuals with UCDs for liver disease. Thus, we systematically evaluated the potential utility of several non-invasive biomarkers for liver fibrosis in UCDs. METHODS We evaluated grey-scale ultrasonography, liver stiffness obtained from shear wave elastography (SWE), and various serum biomarkers for hepatic fibrosis and necroinflammation, in a cohort of 28 children and adults with various UCDs. RESULTS Overall, we demonstrate a high burden of liver disease in our participants with 46% of participants having abnormal grey-scale ultrasound pattern of the liver parenchyma, and 52% of individuals having increased liver stiffness. The analysis of serum biomarkers revealed that 32% of participants had elevated FibroTest™ score, a marker for hepatic fibrosis, and 25% of participants had increased ActiTest™ score, a marker for necroinflammation. Interestingly, liver stiffness did not correlate with ultrasound appearance or FibroTest™. CONCLUSION Overall, our results demonstrate the high overall burden of liver disease in UCDs and highlights the need for further studies exploring new tools for identifying and monitoring individuals with UCDs who are at risk for this complication. TRIAL REGISTRATION This study has been registered in ClinicalTrials.gov (NCT03721367).
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MESH Headings
- Adolescent
- Adult
- Argininosuccinate Lyase/blood
- Biomarkers/blood
- Child
- Child, Preschool
- Elasticity Imaging Techniques
- Female
- Genetic Diseases, Inborn/blood
- Genetic Diseases, Inborn/diagnostic imaging
- Genetic Diseases, Inborn/genetics
- Genetic Diseases, Inborn/pathology
- Humans
- Hyperammonemia/blood
- Hyperammonemia/genetics
- Hyperammonemia/metabolism
- Hyperammonemia/pathology
- Liver/diagnostic imaging
- Liver/pathology
- Liver Cirrhosis/blood
- Liver Cirrhosis/diagnostic imaging
- Liver Cirrhosis/genetics
- Liver Cirrhosis/pathology
- Liver Diseases/blood
- Liver Diseases/genetics
- Liver Diseases/metabolism
- Liver Diseases/pathology
- Male
- Metabolism, Inborn Errors/genetics
- Middle Aged
- Ultrasonography
- Urea Cycle Disorders, Inborn/blood
- Urea Cycle Disorders, Inborn/genetics
- Urea Cycle Disorders, Inborn/metabolism
- Urea Cycle Disorders, Inborn/pathology
- Young Adult
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Affiliation(s)
- Sandesh C S Nagamani
- Department of Molecular & Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA
| | - Saima Ali
- Department of Molecular & Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Rima Izem
- Division of Biostatistics and Study Methodology, Children's National Research Institute, Silver Spring, MD, USA; Department of Pediatrics, George Washington University, Washington, DC, USA; Department of Epidemiology, George Washington University, Washington, DC, USA
| | - Deborah Schady
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Prakash Masand
- Texas Children's Hospital, Houston, TX, USA; Edward B. Singleton Department of Radiology, Texas Children's Hospital, Houston, TX 77030, USA
| | - Benjamin L Shneider
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX, USA
| | - Daniel H Leung
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX, USA
| | - Lindsay C Burrage
- Department of Molecular & Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA.
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22
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Abstract
CLINICAL ISSUE Abdominal complications are often the first indications for cystic fibrosis (CF), a multiorgan disease. A broad range of abdominal manifestations are associated with the disease, including gastrointestinal abnormalities (such as meconium ileus in newborns and distal intestinal obstruction syndrome in older children) and hepatobiliary alterations (e.g., cholelithiasis, microgallbladder, hepatosteatosis, biliary cirrhosis). A characteristic finding is pancreatic involvement, which leads to exocrine and over the course of time to endocrine insufficiency. STANDARD RADIOLOGICAL METHODS Ultrasonography is the preferred and often sole modality for a precise diagnosis of abdominal CF manifestations. However, all imaging modalities can be used, depending on the pathology: X‑ray, fluoroscopic examinations, computed tomography, magnetic resonance imaging (also with application of magnetic resonance cholangiopancreatography). METHODICAL INNOVATIONS/PERFORMANCE Scoring systems are useful for standardized diagnostics. Sonographic findings, described using a scoring system, correlate with clinical symptoms, such as pancreatic lipomatosis with abdominal pain (p = 0.018), flatulence (p = 0.006), and gastroesophageal reflux (p = 0.006). EVALUATION/PRACTICAL RECOMMENDATIONS A standardized approach with structured reporting is important due to the numerous abdominal CF manifestations. To enable precise follow-up analyses, scoring systems based on sonographic findings are excellent.
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