A biliary milestone: functional expression of the human bile salt export pump

Comprehensive bile acid profiling in hereditary intrahepatic cholestasis: Genetic and clinical correlations

BACKGROUND & AIMS

Genetic defects causing dysfunction in bile salt export pump (BSEP/ABCB11) lead to liver diseases. ABCB11 mutations alter the bile acid metabolome. We asked whether profiling plasma bile acids could reveal compensatory mechanisms and track genetic and clinical status.

METHODS

We compared plasma bile acids in 17 ABCB11-mutated patients, 35 healthy controls and 12 genetically undiagnosed cholestasis patients by ultra-high-performance liquid chromatography/multiple-reaction monitoring-mass spectrometry (UPLC/MRM-MS). We developed an index to rank bile acid hydrophobicity, and thus toxicity, based on LC retention times. We recruited 42 genetically diagnosed hereditary cholestasis patients, of whom 12 were presumed to have impaired BSEP function but carried mutations in genes other than ABCB11, and 8 healthy controls, for further verification.

RESULTS

The overall hydrophobicity indices of total bile acids in both the ABCB11-mutated group (11.89 ± 1.07 min) and the undiagnosed cholestasis group (11.46 ± 1.07 min) were lower than those of healthy controls (13.69 ± 0.77 min) (both p < 0.005). This was owing to increased bile acid modifications. Secondary bile acids were detected in patients without BSEP expression, suggesting biliary bile acid secretion through alternative routes. A diagnostic panel comprising lithocholic acid (LCA), tauro-LCA, glyco-LCA and hyocholic acid was identified that could differentiate the ABCB11-mutated cohort from healthy controls and undiagnosed cholestasis patients (AUC=0.946, p < 0.0001) and, in non-ABCB11-mutated cholestasis patients, could distinguish BSEP dysfunction from normal BSEP function (9/12 vs 0/38, p < 0.0000001).

CONCLUSIONS

Profiling of plasma bile acids has provided insights into cholestasis alleviation and may be useful for the clinical management of cholestatic diseases.

Do recommended textbooks contain adequate information about bile salt transporters for medical students?

Several studies have recently highlighted a number of limitations in medical textbooks. The aims of this study were to 1) to assess whether available medical textbooks provided students with adequate information about bile salt transporters, 2) compare the level of detail and the amount of information provided in current textbooks on hepatic transport mechanisms with those available in the literature, and 3) compare the amount of information provided in medical textbooks on hepatocyte transport mechanisms with those involving other transporters e.g., those found in the nephron. Seventy medical textbooks from disciplines including physiology, pathology, cell biology, medicine, pediatrics, pharmacology, pathophysiology, and histology published during the past six years were examined. The literature on bile salt transport has been searched mainly from the Internet (MEDLINE and PubMed). Most textbooks failed to provide any information on transporters found in the basolateral and canalicular membranes of hepatocytes. There are also deficiencies in information on bile salt transporters in the terminal ileum. However, up to the end of 2002, 3,610 articles and reviews had been published on hepatobiliary and enterocyte transport of bile salts. During the same period (from 1965), 10,757 articles had been published on renal transport. Thus the contents of textbooks may reflect the overall volume of research knowledge on renal transport. However, despite our current understanding of hepatic and intestinal transport of bile salts and extensive research, particularly over the past 12 years, there are major deficiencies in textbooks in this area. These findings indicate that there is an imbalance in the contents of current textbooks and a lack of information about hepatobiliary physiology, bile salt transporters, bile formation, and mechanisms underlying cholestasis and drug-induced injury. Authors, editors, and publishers of medical textbooks should consider the need to update the information provided on bile salt transporters.

The bile salt export pump: molecular properties, function and regulation

Secretion of bile salts from the hepatocyte into bile is the major driving force for the generation of bile flow. Identification of the bile salt export pump (BSEP, ABCB11) as the main adenosine-triphosphate-dependent bile salt transporter in mammalian liver has led to a greater understanding of the biliary bile salt secretory process and its regulation. The biology and pathobiology of BSEP have been the subject of many recent studies. Thus, it has been recognized that while mutations in the gene encoding BSEP are responsible for a subgroup of progressive familial cholestasis (progressive familial intrahepatic cholestasis subtype 2), a pediatric cholestatic disorder that may progress to cirrhosis, defective expression or function of BSEP may underlie some forms of drug-induced cholestasis. The present review summarizes recent data on the molecular properties and regulation of BSEP, as well as the clinical implications of absent or defective function of this hepatic efflux pump.

Cholestatic syndromes

Further insights into the cellular and molecular mechanisms underlying hepatobiliary transport function and its regulation now permit a better understanding of the pathogenesis and treatment options of cholestatic liver diseases. Identification of the molecular basis of hereditary cholestatic syndromes will result in an improved diagnosis and management of these conditions. New insights into the pathogenesis of extrahepatic manifestations of cholestasis (eg, pruritus) have facilitated new treatment strategies. Important new studies have been published about the pathogenesis, clinical features, diagnosis, and treatment of primary biliary cirrhosis, primary sclerosing cholangitis, cholestasis of pregnancy, total parenteral nutrition-induced cholestasis, drug-induced cholestasis, and viral cholestatic syndromes.