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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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Krzyżanowska-Jankowska P, Nowak J, Karaźniewicz-Łada M, Jamka M, Klapkova E, Kurek S, Drzymała-Czyż S, Lisowska A, Wojsyk-Banaszak I, Skorupa W, Szydłowski J, Prusa R, Walkowiak J. Vitamin K Status Based on K1, MK-4, MK-7, and Undercarboxylated Prothrombin Levels in Adolescent and Adult Patients with Cystic Fibrosis: A Cross-Sectional Study. Nutrients 2024; 16:1337. [PMID: 38732584 PMCID: PMC11085146 DOI: 10.3390/nu16091337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
The available evidence on vitamin K status in cystic fibrosis (CF) is scarce, lacking data on vitamin K2 (menaquinones-MK). Therefore, we assessed vitamin K1, MK-4 and MK-7 concentrations (LC-MS/MS) in 63 pancreatic insufficient and modulator naïve CF patients, and compared to 61 healthy subjects (HS). Vitamin K1 levels did not differ between studied groups. MK-4 concentrations were higher (median <1st-3rd quartile>: 0.778 <0.589-1.086> vs. 0.349 <0.256-0.469>, p < 0.0001) and MK-7 levels lower (0.150 <0.094-0.259> vs. 0.231 <0.191-0.315>, p = 0.0007) in CF patients than in HS. MK-7 concentrations were higher in CF patients receiving K1 and MK-7 supplementation than in those receiving vitamin K1 alone or no supplementation. Moreover, vitamin K1 concentrations depended on the supplementation regime. Based on multivariate logistic regression analysis, we have found that MK-7 supplementation dose has been the only predictive factor for MK-7 levels. In conclusion, vitamin K1 levels in CF are low if not currently supplemented. MK-4 concentrations in CF patients supplemented with large doses of vitamin K1 are higher than in HS. MK-7 levels in CF subjects not receiving MK-7 supplementation, with no regard to vitamin K1 supplementation, are low. There do not seem to be any good clinical predictive factors for vitamin K status.
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Affiliation(s)
- Patrycja Krzyżanowska-Jankowska
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznan, Poland; (J.N.); (M.J.); (S.K.); (J.W.)
| | - Jan Nowak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznan, Poland; (J.N.); (M.J.); (S.K.); (J.W.)
| | - Marta Karaźniewicz-Łada
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Rokietnicka Street 3, 60-806 Poznan, Poland;
| | - Małgorzata Jamka
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznan, Poland; (J.N.); (M.J.); (S.K.); (J.W.)
| | - Eva Klapkova
- Department of Medical Chemistry and Clinical Biochemistry, 2nd Faculty of Medicine, Charles University, V Úvalu 84, 150 06 Prague, Czech Republic; (E.K.); (R.P.)
| | - Szymon Kurek
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznan, Poland; (J.N.); (M.J.); (S.K.); (J.W.)
| | - Sławomira Drzymała-Czyż
- Department of Bromatology, Poznan University of Medical Sciences, Rokietnicka Street 3, 60-806 Poznan, Poland;
| | - Aleksandra Lisowska
- Department of Pediatric Diabetes, Auxology and Obesity, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznan, Poland;
| | - Irena Wojsyk-Banaszak
- Department of Pneumonology, Allergology and Clinical Immunology, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznan, Poland;
| | - Wojciech Skorupa
- Department of Lung Diseases, Institute for Tuberculosis and Lung Diseases, Plocka Street 26, 01-138 Warsaw, Poland;
| | - Jarosław Szydłowski
- Department of Pediatric Otolaryngology, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznan, Poland;
| | - Richard Prusa
- Department of Medical Chemistry and Clinical Biochemistry, 2nd Faculty of Medicine, Charles University, V Úvalu 84, 150 06 Prague, Czech Republic; (E.K.); (R.P.)
| | - Jarosław Walkowiak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznan, Poland; (J.N.); (M.J.); (S.K.); (J.W.)
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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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Kadouh NK, Elijah J, Fitzgerald LJ, Phan H. Use of CFTR modulators in special populations, part 3: Solid organ transplant. Pediatr Pulmonol 2023; 58:3393-3402. [PMID: 37067449 DOI: 10.1002/ppul.26396] [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: 11/20/2022] [Revised: 02/19/2023] [Accepted: 03/15/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Solid organ transplant (SOT) recipients with cystic fibrosis (CF) may benefit from the pulmonary and extrapulmonary benefits associated with CF transmembrane conductance regulator modulators. Nevertheless, evolution of modulator safety and efficacy data prompts consideration. METHODS The search terms "transplant" AND "ivacaftor"(IVA) OR "lumacaftor"(LUM) OR "tezacaftor" (TEZ) OR "elexacaftor" (ELX) were utilized to conduct a scoping review of English articles from the period of January 1, 2012 to December 31, 2022. Search results from PubMed and Embase databases were reviewed by title and abstract for relevance. Included studies reported efficacy and safety outcomes of modulators in SOT recipients. RESULTS One hundred thirty-six patients from one cohort study (90 lung transplant recipients) and eight case reports and series (29 lung transplant recipients, 16 liver transplant recipients and one lung/liver transplant patient) were included. Post-modulator initiation, 33 patients did not necessitate tacrolimus dose adjustments, 10 required dose uptitration, and 43 required dose reductions. Moreover, LUM/IVA use with azole antifungals may lead to subtherapeutic levels but opposing effects sustained tacrolimus levels. Liver transplant recipients were more likely to experience elevations in transaminases requiring pharmacologic or medical interventions. Majority of patients experienced improvements in pulmonary function, fasting blood glucose, hemoglobin, body mass index, and rhinosinusitis symptoms. However, intolerance or lack of benefit prompted discontinuation of ELX/TEZ/IVA in over 40% of lung-transplant recipients in one study. CONCLUSION Modulator therapy has been reported to produce pulmonary and extra-pulmonary benefits in the CF population with SOT. Considerations for modulator therapy initiation ought to include modulator pharmacokinetics, concomitant medications, and transplant type due to the complex nature of SOT recipients.
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Affiliation(s)
- Nour K Kadouh
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph Elijah
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Linda J Fitzgerald
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- Sanofi Medical Affairs, Bridgewater, New Jersey, USA
| | - Hanna Phan
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, Michigan, USA
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Lusman SS. Update on Cystic Fibrosis in Pediatric Patients. Curr Gastroenterol Rep 2023; 25:308-315. [PMID: 37653358 DOI: 10.1007/s11894-023-00896-3] [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] [Accepted: 08/17/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE OF REVIEW Cystic fibrosis is an inherited, multisystem disease that affects the gastrointestinal system in numerous ways. This article reviews the nutritional, gastrointestinal, and hepatobiliary manifestations of cystic fibrosis with an emphasis on the effects of CFTR modulator therapy. RECENT FINDINGS The life expectancy of individuals with cystic fibrosis has increased substantially in recent years. CFTR modulator therapy improves pulmonary function and results in weight gain. An individualized approach to nutrition is encouraged. Pancreatic exocrine function may improve with intervention early in life. The use of non-invasive methods to screen for hepatobiliary involvement is recommended. Highly effective CFTR modulators lead to increased survival and improved quality of life for many individuals. Their effects on gastrointestinal symptoms and hepatobiliary disease are not fully understood. Patient-reported outcome measures and biomarkers are important clinical endpoints for studying the effects of modulators.
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Affiliation(s)
- Sarah Shrager Lusman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, 622 West 168th Street, PH 17 East - 105L, New York, NY, 10032, USA.
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Olivença DV, Davis JD, Kumbale CM, Zhao CY, Brown SP, McCarty NA, Voit EO. Mathematical models of cystic fibrosis as a systemic disease. WIREs Mech Dis 2023; 15:e1625. [PMID: 37544654 PMCID: PMC10843793 DOI: 10.1002/wsbm.1625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 06/22/2023] [Accepted: 07/06/2023] [Indexed: 08/08/2023]
Abstract
Cystic fibrosis (CF) is widely known as a disease of the lung, even though it is in truth a systemic disease, whose symptoms typically manifest in gastrointestinal dysfunction first. CF ultimately impairs not only the pancreas and intestine but also the lungs, gonads, liver, kidneys, bones, and the cardiovascular system. It is caused by one of several mutations in the gene of the epithelial ion channel protein CFTR. Intense research and improved antimicrobial treatments during the past eight decades have steadily increased the predicted life expectancy of a person with CF (pwCF) from a few weeks to over 50 years. Moreover, several drugs ameliorating the sequelae of the disease have become available in recent years, and notable treatments of the root cause of the disease have recently generated substantial improvements in health for some but not all pwCF. Yet, numerous fundamental questions remain unanswered. Complicating CF, for instance in the lung, is the fact that the associated insufficient chloride secretion typically perturbs the electrochemical balance across epithelia and, in the airways, leads to the accumulation of thick, viscous mucus and mucus plaques that cannot be cleared effectively and provide a rich breeding ground for a spectrum of bacterial and fungal communities. The subsequent infections often become chronic and respond poorly to antibiotic treatments, with outcomes sometimes only weakly correlated with the drug susceptibility of the target pathogen. Furthermore, in contrast to rapidly resolved acute infections with a single target pathogen, chronic infections commonly involve multi-species bacterial communities, called "infection microbiomes," that develop their own ecological and evolutionary dynamics. It is presently impossible to devise mathematical models of CF in its entirety, but it is feasible to design models for many of the distinct drivers of the disease. Building upon these growing yet isolated modeling efforts, we discuss in the following the feasibility of a multi-scale modeling framework, known as template-and-anchor modeling, that allows the gradual integration of refined sub-models with different granularity. The article first reviews the most important biomedical aspects of CF and subsequently describes mathematical modeling approaches that already exist or have the potential to deepen our understanding of the multitude aspects of the disease and their interrelationships. The conceptual ideas behind the approaches proposed here do not only pertain to CF but are translatable to other systemic diseases. This article is categorized under: Congenital Diseases > Computational Models.
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Affiliation(s)
- Daniel V. Olivença
- Center for Engineering Innovation, The University of Texas at Dallas, 800 W. Campbell Road, Richardson, Texas 75080, USA
| | - Jacob D. Davis
- Department of Biomedical Engineering, Georgia Tech and Emory University, Atlanta, Georgia
| | - Carla M. Kumbale
- Department of Biomedical Engineering, Georgia Tech and Emory University, Atlanta, Georgia
| | - Conan Y. Zhao
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Samuel P. Brown
- Department of Biological Sciences, Georgia Tech and Emory University, Atlanta, Georgia
| | - Nael A. McCarty
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Eberhard O. Voit
- Department of Biomedical Engineering, Georgia Tech and Emory University, Atlanta, Georgia
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Frantzen T, Barsky S, LaVecchia G, Marowitz M, Wang J. Evolving Nutritional Needs in Cystic Fibrosis. Life (Basel) 2023; 13:1431. [PMID: 37511806 PMCID: PMC10381916 DOI: 10.3390/life13071431] [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: 05/04/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 07/30/2023] Open
Abstract
The course of cystic fibrosis (CF) as a nutritional illness is diverging since the introduction of highly effective modulator therapy, leading to more heterogeneous phenotypes of the disease despite CF genetic mutations that portend worse prognosis. This may become more evident as we follow the pediatric CF population into adulthood as some highly effective modulator therapies (HEMT) are approved for those as young as 1 year old. This review will outline the current research and knowledge available in the evolving nutritional health of people with CF as it relates to the impact of HEMT on anthropometrics, body composition, and energy expenditure, exocrine and endocrine pancreatic insufficiencies (the latter resulting in CF-related diabetes), vitamin and mineral deficiencies, and nutritional health in CF as it relates to pregnancy and lung transplantation.
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Affiliation(s)
- Theresa Frantzen
- Division of Pulmonary, Critical Care and Sleep Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, NY 11042, USA
| | - Sara Barsky
- Division of Pediatric Pulmonology, The Steven and Alexandra Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, NY 11042, USA
| | - Geralyn LaVecchia
- Division of Pulmonary, Critical Care and Sleep Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, NY 11042, USA
| | - Michelle Marowitz
- Division of Pediatric Pulmonology, The Steven and Alexandra Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, NY 11042, USA
| | - Janice Wang
- Division of Pulmonary, Critical Care and Sleep Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, NY 11042, USA
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Sakhuja S, Staples HM, Minard CG, Ramm LE, Lewindon PJ, Ramm GA, Leung DH. Risk factors for more rapid progression of severe liver fibrosis in children with cystic fibrosis-related liver disease: A multi-center study validated by liver biopsy. Liver Int 2023; 43:1277-1286. [PMID: 37035868 DOI: 10.1111/liv.15572] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/15/2023] [Accepted: 03/18/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND AND AIMS Early identification of risk factors for the development of severe fibrosis in children with cystic fibrosis-related liver disease (CFLD) is crucial as promising therapies emerge. METHODS This multi-center cohort study of children with a priori defined CFLD from 1999 to 2016, was designed to evaluate the clinical utility of CF-specific characteristics and liver biomarkers assessed years prior to liver biopsy-proven CFLD to predict risk of developing severe fibrosis (F3-4) over time. Fibrosis was staged by Metavir classification. RESULTS The overall study cohort of 42 patients (F0-2 (n = 22) and F3-4 (n = 20)) was 57% male (n = 24) with median age of 7.6 years at baseline visit versus 10.3 years at biopsy. Median FEV1 % predicted was lower in F3-4 participants at baseline versus F0-2 (59% vs. 85%; p = .002), while baseline FIB-4, APRI and GGT were higher in F3-4. Median splits for FIB-4 (≥.13), APRI (≥.36), GPR (≥.09), GGT (≥25.5), and FEV1 % (<64%) were associated with more rapid progression to F3-4 (p < .01 for all). Using a combination of change/year in FIB-4, APRI, and GPR to predict F3-4, the AUROC was .81 (95% CI, .66, .96; p < .0001). For up to 5.8 years prior, thresholds for GPR were met 6.5-fold more rapidly, and those for APRI and FIB-4 were met 2.5-fold more rapidly, in those who progressed to F3-4 than those that did not. CONCLUSIONS This study suggests mild-moderate pulmonary dysfunction and higher liver biomarker indices at baseline may be associated with faster progression of CFLD.
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Affiliation(s)
- Shruti Sakhuja
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Gastroenterology, Hepatology, Nutrition, Texas Children's Hospital, Houston, Texas, USA
| | - Heather M Staples
- Department of Pediatrics, University of South Carolina School of Medicine, Columbia, South Carolina, USA
- Division of Pediatric Pulmonology, Prisma Health Children's Hospital-Midlands, Columbia, South Carolina, USA
| | - Charles G Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas, USA
| | - Louise E Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Peter J Lewindon
- Department of Gastroenterology, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Grant A Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Daniel H Leung
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Gastroenterology, Hepatology, Nutrition, Texas Children's Hospital, Houston, Texas, USA
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9
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Collaco JM, Albon D, Ostrenga JS, Flume P, Schechter MS, Cromwell EA. Factors associated with receiving CF care and use of telehealth in 2020 among persons with Cystic Fibrosis in the United States. J Cyst Fibros 2022:S1569-1993(22)01424-2. [DOI: 10.1016/j.jcf.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/08/2022] [Accepted: 12/06/2022] [Indexed: 12/15/2022]
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10
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Muacevic A, Adler JR, Farhat H, Irfan H, Muthiah K, Pallipamu N, Taheri S, Thiagaraj SS, Hamid P. The Usefulness of Combining Noninvasive Methods for Early Identification and Potential Prevention of Cystic Fibrosis-Associated Liver Disease. Cureus 2022; 14:e32340. [PMID: 36628032 PMCID: PMC9826601 DOI: 10.7759/cureus.32340] [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: 09/30/2022] [Accepted: 12/09/2022] [Indexed: 12/13/2022] Open
Abstract
Cystic fibrosis-associated liver disease is the third leading cause of morbidity and mortality in patients with cystic fibrosis (CF). Liver damage in the course of CF ranges from biochemical abnormalities to full-blown cirrhosis and may involve complicated processes like inflammation, fibrogenesis, remodeling, apoptosis, and cholestasis. Despite robust research in the field of CF, its complex pathogenesis is not fully understood. Because of the unknown pathogenesis, it is difficult to develop a highly sensitive and specific test or technology that is standardized, acceptable, and available at most pediatric institutions. The Cystic Fibrosis Foundation (CFF) recommends annual blood tests to screen for liver pathology, which often fails to identify early-onset liver disease. In this review article, we present the use of different liver indices and imaging modalities that can help identify liver disease at the onset and may help in its prevention. Although the disease is commonly diagnosed in the pediatric population, due to increased life expectancy, there is increasing evidence of liver disease in adults too. We believe that the tools we present in this review will help in the prevention of liver disease and thereby reduce the associated morbidity and mortality.
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11
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Shape JM, Sala MA. Nutrition management in adults with cystic fibrosis. Nutr Clin Pract 2022; 37:256-264. [PMID: 35118712 DOI: 10.1002/ncp.10842] [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: 10/23/2021] [Revised: 12/27/2021] [Accepted: 12/29/2021] [Indexed: 11/12/2022] Open
Abstract
Cystic fibrosis (CF) is a lethal, monogenic, autosomal recessive disease with manifestations in multiple organ systems, including the lungs and gastrointestinal tract, that impact adequate nutrition. This review discusses important aspects of nutrition in adults with CF with a focus on exocrine pancreatic insufficiency, CF-related diabetes, and gastrointestinal motility, as well as how advanced lung disease, CF transmembrane conductance regulator modulators, and aging impact nutrition in CF.
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Affiliation(s)
- Jessica M Shape
- Clinical Nutrition Services, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Marc A Sala
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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12
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Ragan H, Autry E, Bomersback T, Hewlett J, Kormelink L, Safirstein J, Shanley L, Lubsch L. The use of elexacaftor/tezacaftor/ivacaftor in patients with cystic fibrosis postliver transplant: A case series. Pediatr Pulmonol 2022; 57:411-417. [PMID: 34850610 DOI: 10.1002/ppul.25779] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 10/31/2021] [Accepted: 11/13/2021] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Cystic fibrosis (CF)-related liver disease (CFLD) manifests as a wide spectrum of hepatobiliary disease and can progress to need liver transplantation. Elexacaftor/tezacaftor/ivacaftor (elx/tez/iva) is a cystic fibrosis transmembrane conductance regulator modulator that has superior efficacy compared to previously approved modulators. Use of elx/tez/iva, should be approached with caution in individuals with CFLD or following liver transplantation due to possible increases in liver function tests (LFTs) and drug-drug interactions with several immunosuppressant medications. OBJECTIVE The purpose of this case series is to explore if the use of elx/tez/iva is safe and tolerable in patients with CF postliver transplantation. METHODS A retrospective case series including patients prescribed elx/tez/iva following liver transplantation and an immunosuppressive regimen consisting of drug therapy metabolized by P-glycoprotein was completed. RESULTS Ten patients at six CF centers with a median age of 22.1 years (range 14-43.4 years) and the median time from the transplant of 6.9 years (range 0.6-22 years) were included. Most patients (8, 80%) received a reduced or full dose of elx/tez/iva for a mean duration of 10.4 months (range 7-12 months). Fluctuations in LFTs occurred in all patients (10, 100%) and led to therapy discontinuation in two patients (20%). Elx/tez/iva initiation resulted in elevations in tacrolimus trough concentration in seven patients (70%). Most patients who tolerated elx/tez/iva had symptomatic and quality of life improvement, increased body mass index, and maintained or improved lung function. CONCLUSION Initiation of elx/tez/iva in patients with CF who received liver transplantation may be safe with clinical benefits.
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Affiliation(s)
- Hunter Ragan
- Goldfarb School of Nursing at Barnes-Jewish College, St. Louis, Missouri, USA
| | - Elizabeth Autry
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA.,Department of Pharmacy Practice and Sciences, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | | | - Jennifer Hewlett
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lauren Kormelink
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA.,Department of Pharmacy Practice and Sciences, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Julie Safirstein
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Laura Shanley
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lisa Lubsch
- Goldfarb School of Nursing at Barnes-Jewish College, St. Louis, Missouri, USA.,SSM Cardinal Glennon Children's Hospital, St. Louis, Missouri, USA
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13
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Marinero Martínez-Lázaro A, Girón Moreno RM, Casals Seoane F, Cano-Valderrama Ó, García-Buey L. Cystic fibrosis with liver involvement in adults has a benign course. Results from a tertiary referral centre cohort. REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS 2022; 114. [DOI: 10.17235/reed.2022.9289/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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14
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Bhatia S, Jakeman B, Cotton C, Ryan K, Bader H, Thomas E, Heynekamp T. Delayed HIV diagnosis in a cystic fibrosis patient: Not just another exacerbation. Respir Med Case Rep 2021; 34:101545. [PMID: 34849336 PMCID: PMC8608600 DOI: 10.1016/j.rmcr.2021.101545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/05/2021] [Accepted: 11/07/2021] [Indexed: 11/19/2022] Open
Abstract
Patients with cystic fibrosis (CF) are living longer due to advancements in treatment. We present a patient with CF in whom diagnoses of Human Immunodeficiency Virus (HIV) and severe pneumocystis pneumonia were delayed due to anchor bias. Our case highlights the importance of routine age-appropriate health screenings in patients with CF. In addition, we discuss the number of management challenges that may arise in patients with a dual diagnosis of CF and HIV.
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Affiliation(s)
- Sapna Bhatia
- Department of Internal Medicine, Division of Pulmonary Critical Care and Sleep Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Bernadette Jakeman
- Department of Pharmacy Practice and Administrative Sciences, University of New Mexico College of Pharmacy, Albuquerque, NM, USA
| | - Carolyn Cotton
- Department of Internal Medicine, Division of Pulmonary Critical Care and Sleep Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Keenan Ryan
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Husam Bader
- Department of Internal Medicine, Division of Pulmonary Critical Care and Sleep Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Elaine Thomas
- Department of Internal Medicine, Division of Infectious Diseases, University of New Mexico Hospital, Albuquerque, NM, 87106, USA
| | - Theresa Heynekamp
- Department of Internal Medicine, Division of Pulmonary Critical Care and Sleep Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
- Corresponding author. Lovelace Medical Group, 500 Walter St NE, Suite 501, Albuquerque, NM, 87102, USA.
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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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Martonosi ÁR, Soós A, Rumbus Z, Hegyi P, Izsák V, Pázmány P, Imrei M, Váncsa S, Szakács Z, Párniczky A. Non-invasive Diagnostic Tests in Cystic Fibrosis-Related Liver Disease: A Diagnostic Test Accuracy Network Meta-Analysis. Front Med (Lausanne) 2021; 8:598382. [PMID: 34386504 PMCID: PMC8353091 DOI: 10.3389/fmed.2021.598382] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 06/25/2021] [Indexed: 11/28/2022] Open
Abstract
Background and Aims: Cystic fibrosis-related liver disease (CFLD) is one of the leading causes of morbidity and mortality in cystic fibrosis (CF). Several non-invasive diagnostic methods have been proposed as screening tools for CFLD. Our aim was to rank all available non-invasive modalities for diagnostic performance. Methods: A systematic search was performed in five medical databases to find studies which reported on any single or composite non-invasive diagnostic test (as an index test) compared to the Debray, the EuroCare or the Colombo criteria (as a reference standard). Ranking was carried out with a Bayesian diagnostic test accuracy network meta-analysis based on superiority indices, calculated for pooled sensitivity (Se) and specificity (Sp) with a 95% confidence interval (CI). The study was registered under CRD42020155846 in PROSPERO. Results: Fifteen studies with 15 index tests and a combination of them were included. The New criteria proposed by Koh et al. – which represent a composite diagnostic definition for CFLD including liver biochemistry, ultrasonography, transient elastography and fibrosis markers—had the best performance for detecting CFLD (Se:94%[CI:58–100], Sp:72%[CI:52–84]); while transient elastography (Se:65%[CI:56–74], Sp:88%[CI:84–91]) and a combination of it with a tissue inhibitor of metalloproteinase-4 measurement (Se:78%[CI:30–100], Sp:64%[CI:18–95%]) proved to be the second and third best options, respectively. In the imaging techniques subgroup, transient elastography (Se:66%[CI:57–72], Sp:88%[CI:85–91%]), acoustic radiation force impulse in the right lobe (Se:54%[CI:33–74], Sp:88%[CI:66–96]) and that in the left lobe (Se:55%[CI:23–81], Sp:82%[CI:50–95]) were ranked the highest. Comparing biochemical markers/fibrosis indices, the measurement of the Forns index (Se:72%[CI:25–99], Sp:63%[CI:16–94]), the aspartate aminotransferase-to-platelet ratio (Se:55%[CI:41–68], Sp:83%[CI:66–89]) and alkaline phosphatase (Se:63%[CI:18–93], Sp:64%[CI:19–95]) were ranked the highest. Conclusion: The New criteria show the best diagnostic performance. In clinical practice, transient elastography seems to be a simple, cheap and non-invasive tool, outperforming imaging, biochemical and fibrosis tests for detecting CFLD. Further studies are needed to validate our findings.
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Affiliation(s)
- Ágnes Rita Martonosi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Alexandra Soós
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zoltán Rumbus
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Vera Izsák
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Piroska Pázmány
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Marcell Imrei
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Szilárd Váncsa
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Andrea Párniczky
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
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17
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Clinical use of shear-wave elastography for detecting liver fibrosis in children and adolescents with cystic fibrosis. Pediatr Radiol 2021; 51:1369-1377. [PMID: 33759025 PMCID: PMC8823212 DOI: 10.1007/s00247-021-05015-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 12/18/2020] [Accepted: 02/11/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Complications from liver cirrhosis are a leading cause of death in children with cystic fibrosis. Identifying children at risk for developing liver cirrhosis and halting its progression are critical to reducing liver-associated mortality. OBJECTIVE Quantitative US imaging, such as shear-wave elastography (SWE), might improve the detection of liver fibrosis in children with cystic fibrosis (CF) over gray-scale US alone. We incorporated SWE in our pediatric CF liver disease screening program and evaluated its performance using magnetic resonance (MR) elastography. MATERIALS AND METHODS Ninety-four children and adolescents with CF underwent 178 SWE exams, aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT) and platelet measurements. Of these, 27 children underwent 34 MR elastography exams. We evaluated SWE performance using 6-MHz and 9-MHZ point SWE, and 9-MHz two-dimensional (2-D) SWE. RESULTS The 6-MHz point SWE was the only method that correlated with MR elastography (r=0.52; 95% confidence interval [CI] 0.20-0.74; P=0.003). SWE of 1.45 m/s distinguished normal from abnormal MR elastography (79% sensitivity, 100% specificity, 100% positive predictive value [PPV], 55% negative predictive value [NPV], area under the receiver operating characteristic [AUROC] curve 0.94). SWE of 1.84 m/s separated mild-moderate (3.00-4.77 kPa) from severe (>4.77 kPa) MR elastography (88% sensitivity, 86% specificity, 78% PPV, 93% NPV, AUROC 0.79). Elevations of AST, ALT, GGT and thrombocytopenia were associated with higher SWE. AST-to-platelet ratio index of 0.42, fibrosis-4 of 0.29, and GGT-to-platelet ratio of 1.43 all had >95% NPV for SWE >1.84 m/s. CONCLUSION Given its correlation with MR elastography, SWE might be a clinically useful predictor of liver fibrosis. We identified imaging criteria delineating the use of SWE to identify increased liver stiffness in children with CF. With multicenter validation, these data might be used to improve the detection and monitoring of liver fibrosis in children with CF.
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18
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Abstract
Cystic fibrosis (CF) is one of the most commonly diagnosed genetic disorders. Clinical characteristics include progressive obstructive lung disease, sinusitis, exocrine pancreatic insufficiency leading to malabsorption and malnutrition, liver and pancreatic dysfunction, and male infertility. Although CF is a life-shortening disease, survival has continued to improve to a median age of 46.2 years due to earlier diagnosis through routine newborn screening, promulgation of evidence-based guidelines to optimize nutritional and pulmonary health, and the development of CF-specific interdisciplinary care centers. Future improvements in health and quality of life for individuals with CF are likely with the recent development of mutation-specific modulator therapies. In this review, we will cover the current understanding of the disease manifestations, diagnosis, and management as well as common complications seen in individuals with CF.
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Affiliation(s)
- Kimberly M Dickinson
- Eudowood Division of Pediatric Respiratory Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph M Collaco
- Eudowood Division of Pediatric Respiratory Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD
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19
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Staufer K. Current Treatment Options for Cystic Fibrosis-Related Liver Disease. Int J Mol Sci 2020; 21:E8586. [PMID: 33202578 PMCID: PMC7696864 DOI: 10.3390/ijms21228586] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/08/2020] [Accepted: 11/11/2020] [Indexed: 02/07/2023] Open
Abstract
Cystic Fibrosis-related liver disease (CFLD) has become a leading cause of morbidity and mortality in patients with Cystic Fibrosis (CF), and affects children and adults. The understanding of the pathogenesis of CFLD is key in order to develop efficacious treatments. However, it remains complex, and has not been clarified to the last. The search for a drug might be additionally complicated due to the diverse clinical picture and lack of a unified definition of CFLD. Although ursodeoxycholic acid has been used for decades, its efficacy in CFLD is controversial, and the potential of Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) modulators and targeted gene therapy in CFLD needs to be defined in the near future. This review focuses on the current knowledge on treatment strategies for CFLD based on pathomechanistic viewpoints.
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Affiliation(s)
- Katharina Staufer
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, 3010 Bern, Switzerland; ; Tel.: +41-31-63-2-74-88
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20
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Thornton T, Pillai A. Encephalopathy in cystic fibrosis. Paediatr Respir Rev 2020; 35:93-94. [PMID: 32800451 DOI: 10.1016/j.prrv.2020.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 03/31/2020] [Indexed: 11/29/2022]
Abstract
Cystic fibrosis liver disease (CFLD) affects a large proportion of cystic fibrosis (CF) patients; however encephalopathy is a rare complication. While classical hepatic encephalopathy can be a feature of end-stage liver disease, "hyperammonemic encephalopathy" can be precipitated in previously stable CFLD by various triggers including systemic corticosteroids. We describe one such case and review the relevant literature.
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Affiliation(s)
- Tamsin Thornton
- Paediatric Respiratory Department, Norfolk and Norwich University Hospital, Colney Lane, Norwich, Norfolk NR4 7UY, United Kingdom.
| | - Anjay Pillai
- Paediatric Respiratory Department, Norfolk and Norwich University Hospital, Colney Lane, Norwich, Norfolk NR4 7UY, United Kingdom
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21
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Abstract
As improvements in nutritional and pulmonary care increase the life expectancy of cystic fibrosis (CF) patients, CF-associated liver disease (CFLD) is emerging as a cause of mortality. CFLD is the third leading cause of death in CF patients. We performed a search on PubMed and Google Scholar for published articles on CFLD. We reviewed the articles found in the literature search and gave priority to recent publications and studies with larger sample sizes. The prevalence of CFLD in the CF population is around 23% with a range of 2-62% and that prevalence increases linearly with age from 3.7% at age 5 to 32.2% at age 30. CFLD can present clinically in various ways such as hepatomegaly, variceal hemorrhage, persistent elevation of liver enzymes, and micro-gallbladder. Due to the focal nature of fibrosis in majority cases of CFLD, liver biopsies are sparsely performed for diagnosis or the marker of liver fibrosis. Although the mechanism of CFLD development is still unknown, many potential factors are reported. Some mutations of CFTR such as having a homozygous F508del mutation has been reported to increase the risk of developing CFLD and its severity. Having the SERPINA1 Z allele, a history of pancreatic insufficiency, a history meconium ileus, CF-related diabetes, or being male increases the risk of developing CFLD. Environmental factors do not appear to have significant effect on modulating CFLD development. Ursodeoxycholic acid is commonly used to treat or prevent CFLD, but the efficacy of this treatment is questionable.
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Affiliation(s)
- Paul Wasuwanich
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN, USA
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Nutrition, and Hepatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA -
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22
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Cipolli M, Fethney J, Waters D, Zanolla L, Meneghelli I, Dutt S, Assael BM, Gaskin KJ. Occurrence, outcomes and predictors of portal hypertension in cystic fibrosis: A longitudinal prospective birth cohort study. J Cyst Fibros 2020; 19:455-459. [DOI: 10.1016/j.jcf.2019.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 08/29/2019] [Accepted: 09/24/2019] [Indexed: 12/12/2022]
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23
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Siegel MJ, Freeman AJ, Ye W, Palermo JJ, Molleston JP, Paranjape SM, Stoll J, Leung D, Masand P, Karmazyn B, Harned R, Ling SC, Navarro OM, Karnsakul W, Alazraki A, Schwarzenberg SJ, Seidel FG, Towbin A, Alonso EM, Nicholas JL, Murray KF, Otto RK, Sherker AH, Magee JC, Narkewicz MR. Heterogeneous Liver on Research Ultrasound Identifies Children with Cystic Fibrosis at High Risk of Advanced Liver Disease: Interim Results of a Prospective Observational Case-Controlled Study. J Pediatr 2020; 219:62-69.e4. [PMID: 32061406 PMCID: PMC7096278 DOI: 10.1016/j.jpeds.2019.12.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/21/2019] [Accepted: 12/13/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess if a heterogeneous pattern on research liver ultrasound examination can identify children at risk for advanced cystic fibrosis (CF) liver disease. STUDY DESIGN Planned 4-year interim analysis of a 9-year multicenter, case-controlled cohort study (Prospective Study of Ultrasound to Predict Hepatic Cirrhosis in CF). Children with pancreatic insufficient CF aged 3-12 years without known cirrhosis, Burkholderia species infection, or short bowel syndrome underwent a screening research ultrasound examination. Participants with a heterogeneous liver ultrasound pattern were matched (by age, Pseudomonas infection status, and center) 1:2 with participants with a normal pattern. Clinical status and laboratory data were obtained annually and research ultrasound examinations biannually. The primary end point was the development of a nodular research ultrasound pattern, a surrogate for advanced CF liver disease. RESULTS There were 722 participants who underwent screening research ultrasound examination, of which 65 were heterogeneous liver ultrasound pattern and 592 normal liver ultrasound pattern. The final cohort included 55 participants with a heterogeneous liver ultrasound pattern and 116 participants with a normal liver ultrasound pattern. All participants with at least 1 follow-up research ultrasound were included. There were no differences in age or sex between groups at entry. Alanine aminotransferase (42 ± 22 U/L vs 32 ± 19 U/L; P = .0033), gamma glutamyl transpeptidase (36 ± 34 U/L vs 15 ± 8 U/L; P < .001), and aspartate aminotransferase to platelet ratio index (0.7 ± 0.5 vs 0.4 ± 0.2; P < .0001) were higher in participants with a heterogeneous liver ultrasound pattern compared with participants with a normal liver ultrasound pattern. Participants with a heterogeneous liver ultrasound pattern had a 9.1-fold increased incidence (95% CI, 2.7-30.8; P = .0004) of nodular pattern vs a normal liver ultrasound pattern (23% in heterogeneous liver ultrasound pattern vs 2.6% in normal liver ultrasound pattern). CONCLUSIONS Research liver ultrasound examinations can identify children with CF at increased risk for developing advanced CF liver disease.
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Affiliation(s)
- Marilyn J Siegel
- Mallinckrodt Institute of Radiology, Washington
University School of Medicine, St Louis, MO
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and
Nutrition, Emory University School of Medicine, Atlanta, GA
| | - Wen Ye
- Department of Biostatistics, University of Michigan
Medical School, Ann Arbor, MI
| | - 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
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition,
Riley Hospital for Children, Indiana University School of Medicine, Indianapolis,
IN
| | - Shruti M Paranjape
- Division of Pediatric Pulmonology, John Hopkins School of
Medicine, Baltimore, MD
| | - Janis Stoll
- Division of Gastroenterology and Nutrition, Washington
University School of Medicine, St Louis, MO
| | - Daniel Leung
- Division of Gastroenterology, Hepatology and Nutrition,
Texas Children’s Hospital, Houston TX
| | - Prakash Masand
- Division of Radiology, Texas Children’s Hospital,
Houston TX
| | - Boaz Karmazyn
- Pediatric Radiology, Riley Hospital for Children,
Indianapolis, IN
| | - Roger Harned
- Division of Pediatric Radiology, Children’s
Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | - 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, University of Toronto,
Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario,
Canada
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Hepatology and
Nutrition, John Hopkins School of Medicine, Baltimore, MD
| | - Adina Alazraki
- Department of Radiology, Emory University School of
Medicine and Children’s Healthcare of Atlanta, Egleston, Atlanta, GA
| | - Sarah Jane Schwarzenberg
- Pediatric Gastroenterology, University of Minnesota
Masonic Children’s Hospital, Minneapolis, MN
| | - F Glen Seidel
- Pediatric Radiology, Lucile Packard Children’s
Hospital, Stanford, CA
| | - Alex Towbin
- Department of Radiology, Cincinnati Children’s
Hospital Medical Center and Department of Radiology, University of Cincinnati
College of Medicine Cincinnati OH
| | - Estella M Alonso
- Division of Pediatric Gastroenterology, Hepatology and
Nutrition, Ann & Robert H. Lurie Children’s Hospital, Chicago IL
| | - Jennifer L. Nicholas
- Mallinckrodt Institute of Radiology, Washington
University School of Medicine, St Louis, MO
| | - Karen F Murray
- Division of Gastroenterology and Hepatology, University
of Washington and Seattle Children’s Hospital, Seattle, WA
| | - Randolph K Otto
- Department of Radiology, Seattle Children’s
Hospital, Seattle, WA
| | | | - John C Magee
- Department of Surgery, University of Michigan Medical
School, Ann Arbor, MI
| | - 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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Integrating Clinical Ultrasound Into Screening for Cystic Fibrosis Liver Disease: Approach With Caution and Optimism. J Pediatr Gastroenterol Nutr 2019; 69:394-395. [PMID: 31436709 DOI: 10.1097/mpg.0000000000002441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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New Algorithm for the Integration of Ultrasound Into Cystic Fibrosis Liver Disease Screening. J Pediatr Gastroenterol Nutr 2019; 69:404-410. [PMID: 31181020 DOI: 10.1097/mpg.0000000000002412] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Liver nodularity occurs across the spectrum of cystic fibrosis liver disease (CFLD), from regenerative nodules to cirrhosis, and can occur without liver enzyme abnormalities. Our aims were to determine if incorporating abdominal ultrasound (US) with annual laboratory testing improves the detection of CFLD and establish CF-specific thresholds for liver screening labs. METHODS CF patients at least 6 years old who were exocrine pancreatic-insufficient had an US with Doppler and shear wave elastography. Patients were divided into Normal, Echogenic, or Nodular groups, based on US findings. Results were compared with aspartate aminotransferase (AST), alanine aminotransferase (ALT), platelets, AST to platelet ratio index (APRI), Fibrosis 4 (FIB-4), and gamma-glutamyl transferase (GGT) to platelet ratio (GPR). Receiver operator curve, sensitivity, specificity, positive predictive value, negative predictive value, and optimal cut-off with Youden Index were calculated. RESULTS From 82 patients, incorporation of US identified more nodular livers than using labs alone. The Nodular group had significantly greater median AST (44), ALT (48), GGT (46), APRI (0.619), FIB-4 (0.286), GPR (1.431). Optimal cut-offs to detect liver nodularity in CF were AST >33, ALT >45, GGT >21, Platelets <230, APRI >0.367, FIB-4 >0.222, GPR >0.682. Using GGT, APRI, and GPR, we generated an algorithm to direct the use of US in CFLD screening. CONCLUSIONS Using modified serum lab thresholds, addition of liver fibrosis indices, and/or abdominal US can increase detection of liver nodularity in CF. A combination of GGT, GPR, and APRI can help direct which CF children should undergo US evaluation. These tools may improve earlier identification of fibrosis and/or cirrhosis in CF patients.
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Hercun J, Alvarez F, Vincent C, Bilodeau M. Cystic fibrosis liver disease: A condition in need of structured transition and continuity of care. CANADIAN LIVER JOURNAL 2019; 2:71-83. [PMID: 35990223 PMCID: PMC9202747 DOI: 10.3138/canlivj-2018-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 09/10/2018] [Indexed: 08/05/2023]
Abstract
Liver disease affects one-third of patients with cystic fibrosis (CF) and it is one of the major causes of morbidity and mortality in these patients. Historically considered a disease of childhood, its impact is now seen more often in adulthood. The heterogeneous pattern of CF liver disease and its rapid progression to cirrhosis remain a diagnostic challenge and new questions pertaining to the nature of liver involvement have recently been raised. Non-invasive measures to stratify the severity of liver involvement are increasingly used to predict clinical outcomes. A single treatment, ursodeoxycholic acid, has been used to slow progression of liver disease while recent advances in the field of CF treatments are promising. Management of portal hypertension remains challenging but outcomes after liver transplantation are encouraging. While many questions remain unanswered, a growing number of CF patients reach adulthood and will require care for CF liver disease.
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Affiliation(s)
- Julian Hercun
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
| | - Fernando Alvarez
- Gastroenterology, Hepatology and Nutrition Division, CHU Sainte-Justine, Montréal, Québec
| | - Catherine Vincent
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
| | - Marc Bilodeau
- Hepatology Department, Centre Hospitalier de l’Université de Montréal, Montréal, Québec;
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Hatziparasides G, Loukou I, Moustaki M, Douros K. Vitamin K and cystic fibrosis: A gordian knot that deserves our attention. Respir Med 2019; 155:36-42. [PMID: 31295676 DOI: 10.1016/j.rmed.2019.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 06/18/2019] [Accepted: 07/05/2019] [Indexed: 01/16/2023]
Abstract
Cystic fibrosis (CF) is an inherited genetic disorder with multiorgan involvement. Gastrointestinal tract dysfunction leads to fat and fat-soluble vitamins (A,D,E,K) malabsorption and deficiency of these vitamins. Subclinical vitamin K (VK) deficiency seems to be a common problem in CF patients. However, despite the rest of fat-soluble vitamins being routinely supplemented, this is not a universal clinical practice for VK. Inefficient levels of VK may have significant effects on blood coagulation and bone formation. There are also some data indicating that VK may play a key role on regulation of inflammation. Supplementing CF patients with VK seems rational, but the appropriate dosing regimens are still a matter of debate. This review will try to delineate the problem and communicate the latest opinions on this controversial issue.
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Affiliation(s)
- Gregorios Hatziparasides
- Pediatric Allergy and Respiratory Unit, 3rd Department of Pediatrics, University General Hospital "Attikon", School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Loukou
- Cystic Fibrosis Dept, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Maria Moustaki
- Cystic Fibrosis Dept, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Konstantinos Douros
- Pediatric Allergy and Respiratory Unit, 3rd Department of Pediatrics, University General Hospital "Attikon", School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
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The emerging burden of liver disease in cystic fibrosis patients: A UK nationwide study. PLoS One 2019; 14:e0212779. [PMID: 30947265 PMCID: PMC6448894 DOI: 10.1371/journal.pone.0212779] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 02/08/2019] [Indexed: 02/08/2023] Open
Abstract
Objective Cystic fibrosis associated liver disease (CFLD) is the third largest cause of mortality in CF. Our aim was to define the burden of CFLD in the UK using national registry data and identify risk factors for progressive disease. Methods A longitudinal population-based cohort study was conducted. Cases were defined as all patients with CFLD identified from the UK CF Registry, 2008–2013 (n = 3417). Denominator data were derived from the entire UK CF Registry. The burden of CFLD was characterised. Regression analysis was undertaken to identify risk factors for cirrhosis and progression. Results Prevalence of CFLD increased from 203.4 to 228.3 per 1000 patients during 2008–2013. Mortality in CF patients with CFLD was more than double those without; cirrhotic patients had higher all-cause mortality (HR 1.54, 95% CI 1.09 to 2.18, p = 0.015). Median recorded age of cirrhosis diagnosis was 19 (range 5–53) years. Male sex, Pseudomonas airway infection and CF related diabetes were independent risk factors for cirrhosis. Ursodeoxycholic acid use was associated with prolonged survival in patients without cirrhosis. Conclusions This study highlights an important changing disease burden of CFLD. The prevalence is slowly increasing and, importantly, the disease is not just being diagnosed in childhood. Although the role of ursodeoxycholic acid remains controversial, this study identified a positive association with survival.
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Castellani C, Duff AJA, Bell SC, Heijerman HGM, Munck A, Ratjen F, Sermet-Gaudelus I, Southern KW, Barben J, Flume PA, Hodková P, Kashirskaya N, Kirszenbaum MN, Madge S, Oxley H, Plant B, Schwarzenberg SJ, Smyth AR, Taccetti G, Wagner TOF, Wolfe SP, Drevinek P. ECFS best practice guidelines: the 2018 revision. J Cyst Fibros 2018; 17:153-178. [PMID: 29506920 DOI: 10.1016/j.jcf.2018.02.006] [Citation(s) in RCA: 432] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/26/2018] [Accepted: 02/08/2018] [Indexed: 12/12/2022]
Abstract
Developments in managing CF continue to drive dramatic improvements in survival. As newborn screening rolls-out across Europe, CF centres are increasingly caring for cohorts of patients who have minimal lung disease on diagnosis. With the introduction of mutation-specific therapies and the prospect of truly personalised medicine, patients have the potential to enjoy good quality of life in adulthood with ever-increasing life expectancy. The landmark Standards of Care published in 2005 set out what high quality CF care is and how it can be delivered throughout Europe. This underwent a fundamental re-write in 2014, resulting in three documents; center framework, quality management and best practice guidelines. This document is a revision of the latter, updating standards for best practice in key aspects of CF care, in the context of a fast-moving and dynamic field. In continuing to give a broad overview of the standards expected for newborn screening, diagnosis, preventative treatment of lung disease, nutrition, complications, transplant/end of life care and psychological support, this consensus on best practice is expected to prove useful to clinical teams both in countries where CF care is developing and those with established CF centres. The document is an ECFS product and endorsed by the CF Network in ERN LUNG and CF Europe.
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Affiliation(s)
- Carlo Castellani
- Cystic Fibrosis Centre, Azienda Ospedaliera Universitaria Integrata Verona, Italy; Cystic Fibrosis Centre, Gaslini Institute, Genoa, Italy
| | - Alistair J A Duff
- Regional Paediatric CF Unit, Leeds General Infirmary Leeds, UK; Department of Clinical & Health Psychology, St James' University Hospital, Leeds, UK.
| | - Scott C Bell
- Adult Cystic Fibrosis Centre, The Prince Charles Hospital, Brisbane, Australia
| | - Harry G M Heijerman
- Dept of Pulmonology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne Munck
- Hopital Robert Debré Assistante publique-Hôpitaux de Paris, Université Paris 7, Pediatric CF Centre, Paris, France
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada
| | - Isabelle Sermet-Gaudelus
- Service de Pneumologie et Allergologie Pédiatriques, Centre de Ressources et de Compétence de la Mucoviscidose, Institut Necker Enfants Malades/INSERM U1151 Hôpital Necker Enfants Malades, P, France
| | - Kevin W Southern
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Jurg Barben
- Ostschweizer Kinderspital Sankt Gallen, Claudiusstrasse 6, 9006 St. Gallen, Switzerland
| | - Patrick A Flume
- Division of Pulmonary and Critical Care, Medical University of South Carolina, USA
| | - Pavla Hodková
- Department of Clinical Psychology, University Hospital, Prague, Czech Republic
| | - Nataliya Kashirskaya
- Department of Genetic Epidemiology (Cystic Fibrosis Group), Federal State Budgetary Institution, Research Centre for Medical Genetics, Moscow, Russia
| | - Maya N Kirszenbaum
- Department of Pediatric Pulmunology, CRCM, Hôpital Necker-Enfants Malades, Paris, France
| | - Sue Madge
- Cystic Fibrosis Centre, Royal Brompton Hospital, London, UK
| | - Helen Oxley
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Barry Plant
- Cork Adult CF Centre, Cork University Hospital, University College, Cork, Republic of Ireland
| | - Sarah Jane Schwarzenberg
- Divison of Pediatric Gastroenterology Hepatology and Nutrition, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology (COG), University of Nottingham, Nottingham, UK
| | - Giovanni Taccetti
- Cystic Fibrosis Centre, Department of Paediatric Medicine, Anna Meyer Children's University Hospital, Florence, Italy
| | - Thomas O F Wagner
- Frankfurter Referenzzentrum für Seltene Erkrankungen (FRZSE), Universitätsklinikum Frankfurt am Main, Wolfgang von Goethe-Universität, Frankfurt am Main, Germany
| | - Susan P Wolfe
- Regional Paediatric CF Unit, The Leeds Children's Hospital, Leeds Teaching Hospitals, Belmont Grove, Leeds, UK
| | - Pavel Drevinek
- Department of Medical Microbiology, Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
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Ayoub F, Trillo-Alvarez C, Morelli G, Lascano J. Risk factors for hepatic steatosis in adults with cystic fibrosis: Similarities to non-alcoholic fatty liver disease. World J Hepatol 2018; 10:34-40. [PMID: 29399276 PMCID: PMC5787682 DOI: 10.4254/wjh.v10.i1.34] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/06/2017] [Accepted: 12/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the clinical, biochemical and imaging characteristics of adult cystic fibrosis (CF) patients with hepatic steatosis as compared to normal CF controls.
METHODS We performed a retrospective review of adult CF patients in an academic outpatient setting during 2016. Baseline characteristics, genetic mutation analysis as well as laboratory values were collected. Abdominal imaging (ultrasound, computed tomography, magnetic resonance) was used to determine presence of hepatic steatosis. We compare patients with hepatic steatosis to normal controls.
RESULTS Data was collected on 114 patients meeting inclusion criteria. Seventeen patients (14.9%) were found to have hepatic steatosis on imaging. Being overweight (BMI > 25) (P = 0.019) and having a higher ppFEV1 (75 vs 53, P = 0.037) were significantly associated with hepatic steatosis. Patients with hepatic steatosis had a significantly higher median alanine aminotransferase level (27 vs 19, P = 0.048). None of the hepatic steatosis patients had frank CF liver disease, cirrhosis or portal hypertension. We found no significant association with pancreatic insufficiency or CF related diabetes.
CONCLUSION Hepatic steatosis appears to be a clinically and phenotypically distinct entity from CF liver disease. The lack of association with malnourishment and the significant association with higher BMI and higher ppFEV1 demonstrate similarities with non-alcoholic fatty liver disease. Long term prospective studies are needed to ascertain whether CF hepatic steatosis progresses to fibrosis and cirrhosis.
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Affiliation(s)
- Fares Ayoub
- Department of Medicine, University of Florida, Gainesville, FL 32608, United States
| | - Cesar Trillo-Alvarez
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL 32608, United States
| | - Giuseppe Morelli
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States
| | - Jorge Lascano
- Department of Medicine, Adult Cystic Fibrosis Center, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL 32608, United States
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Leung DH, Narkewicz MR. Cystic Fibrosis-related cirrhosis. J Cyst Fibros 2017; 16 Suppl 2:S50-S61. [DOI: 10.1016/j.jcf.2017.07.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/01/2017] [Accepted: 07/03/2017] [Indexed: 12/14/2022]
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Athanazio RA, Silva Filho LVRFD, Vergara AA, Ribeiro AF, Riedi CA, Procianoy EDFA, Adde FV, Reis FJC, Ribeiro JD, Torres LA, Fuccio MBD, Epifanio M, Firmida MDC, Damaceno N, Ludwig-Neto N, Maróstica PJC, Rached SZ, Melo SFDO. Brazilian guidelines for the diagnosis and treatment of cystic fibrosis. ACTA ACUST UNITED AC 2017; 43:219-245. [PMID: 28746534 PMCID: PMC5687954 DOI: 10.1590/s1806-37562017000000065] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 05/22/2017] [Indexed: 12/15/2022]
Abstract
Cystic fibrosis (CF) is an autosomal recessive genetic disorder characterized by dysfunction of the CFTR gene. It is a multisystem disease that most often affects White individuals. In recent decades, various advances in the diagnosis and treatment of CF have drastically changed the scenario, resulting in a significant increase in survival and quality of life. In Brazil, the current neonatal screening program for CF has broad coverage, and most of the Brazilian states have referral centers for the follow-up of individuals with the disease. Previously, CF was limited to the pediatric age group. However, an increase in the number of adult CF patients has been observed, because of the greater number of individuals being diagnosed with atypical forms (with milder phenotypic expression) and because of the increase in life expectancy provided by the new treatments. However, there is still great heterogeneity among the different regions of Brazil in terms of the access of CF patients to diagnostic and therapeutic methods. The objective of these guidelines was to aggregate the main scientific evidence to guide the management of these patients. A group of 18 CF specialists devised 82 relevant clinical questions, divided into five categories: characteristics of a referral center; diagnosis; treatment of respiratory disease; gastrointestinal and nutritional treatment; and other aspects. Various professionals working in the area of CF in Brazil were invited to answer the questions devised by the coordinators. We used the PubMed database to search the available literature based on keywords, in order to find the best answers to these questions.
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Affiliation(s)
- Rodrigo Abensur Athanazio
- . Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | - Alberto Andrade Vergara
- . Hospital Infantil João Paulo II, Rede Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | | | | | | | - Fabíola Villac Adde
- . Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Francisco José Caldeira Reis
- . Hospital Infantil João Paulo II, Rede Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | - José Dirceu Ribeiro
- . Hospital de Clínicas, Universidade Estadual de Campinas, Campinas (SP) Brasil
| | - Lídia Alice Torres
- . Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Marcelo Bicalho de Fuccio
- . Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | - Matias Epifanio
- . Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre (RS) Brasil
| | | | - Neiva Damaceno
- . Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo (SP) Brasil
| | - Norberto Ludwig-Neto
- . Hospital Infantil Joana de Gusmão, Florianópolis (SC) Brasil.,. Serviço de Fibrose Cística e Triagem Neonatal para Fibrose Cística, Secretaria Estadual de Saúde de Santa Catarina, Florianópolis (SC) Brasil
| | - Paulo José Cauduro Maróstica
- . Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil.,. Universidade Federal do Rio Grande do Sul Porto Alegre (RS) Brasil
| | - Samia Zahi Rached
- . Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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Abstract
BACKGROUND Abnormal biliary secretion leads to the thickening of bile and the formation of plugs within the bile ducts; the consequent obstruction and abnormal bile flow ultimately results in the development of cystic fibrosis-related liver disease. This condition peaks in adolescence with up to 20% of adolescents with cystic fibrosis developing chronic liver disease. Early changes in the liver may ultimately result in end-stage liver disease with people needing transplantation. One therapeutic option currently used is ursodeoxycholic acid. This is an update of a previous review. OBJECTIVES To analyse evidence that ursodeoxycholic acid improves indices of liver function, reduces the risk of developing chronic liver disease and improves outcomes in general in cystic fibrosis. SEARCH METHODS We searched the Cochrane CF and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. We also contacted drug companies and searched online trial registries.Date of the most recent search of the Group's trials register: 09 April 2017. SELECTION CRITERIA Randomised controlled trials of the use of ursodeoxycholic acid for at least three months compared with placebo or no additional treatment in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial eligibility and quality. The authors used GRADE to assess the quality of the evidence. MAIN RESULTS Twelve trials have been identified, of which four trials involving 137 participants were included; data were only available from three of the trials (118 participants) since one cross-over trial did not report appropriate data. The dose of ursodeoxycholic acid ranged from 10 to 20 mg/kg/day for up to 12 months. The complex design used in two trials meant that data could only be analysed for subsets of participants. There was no significant difference in weight change, mean difference -0.90 kg (95% confidence interval -1.94 to 0.14) based on 30 participants from two trials. Improvement in biliary excretion was reported in only one trial and no significant change after treatment was shown. There were no data available for analysis for long-term outcomes such as death or need for liver transplantation. AUTHORS' CONCLUSIONS There are few trials assessing the effectiveness of ursodeoxycholic acid. The quality of the evidence identified ranged from low to very low. There is currently insufficient evidence to justify its routine use in cystic fibrosis.
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Affiliation(s)
- Katharine Cheng
- c/o Cochrane CFGD Group, Department of Women's and Children's Health, University of Liverpool, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, UK, L12 2AP
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Koh C, Sakiani S, Surana P, Zhao X, Eccleston J, Kleiner DE, Herion D, Liang TJ, Hoofnagle JH, Chernick M, Heller T. Adult-onset cystic fibrosis liver disease: Diagnosis and characterization of an underappreciated entity. Hepatology 2017; 66:591-601. [PMID: 28422310 PMCID: PMC5519421 DOI: 10.1002/hep.29217] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/22/2017] [Accepted: 04/14/2017] [Indexed: 12/15/2022]
Abstract
UNLABELLED Cystic fibrosis (CF) liver disease (CFLD), a leading cause of death in CF, is mostly described in pediatric populations. Adult-onset CFLD lacks sufficient characterization and diagnostic tools. A cohort of CF patients without CFLD during childhood were followed for up to 38 years with serologic testing, imaging, and noninvasive fibrosis markers. Historical CFLD diagnostic criteria were compared with newly proposed CFLD criteria. Thirty-six CF patients were followed for a median of 24.5 years (interquartile range 15.6-32.9). By the last follow-up, 11 (31%) had died. With conventional criteria, 8 (22%) patients had CFLD; and by the new criteria, 17 (47%) had CFLD at a median age of 36.6 years (interquartile range 26.5-43.2). By the new criteria, those with CFLD had higher median alanine aminotransferase (42 versus 27, P = 0.005), aspartate aminotransferase (AST; 26 versus 21, P = 0.01), direct bilirubin (0.13 versus 0.1, P = 0.01), prothrombin time (14.4 versus 12.4, P = 0.002), and AST-to-platelet ratio index (0.31 versus 0.23, P = 0.003) over the last 2 years of follow-up. Subjects with a FibroScan >6.8 kPa had higher alanine aminotransferase (42 versus 28U/L, P = 0.02), AST (35 versus 25U/L, P = 0.02), AST-to-platelet ratio index (0.77 versus 0.25, P = 0.0004), and Fibrosis-4 index (2.14 versus 0.74, P = 0.0003) and lower platelet counts (205 versus 293, P = 0.02). One CFLD patient had nodular regenerative hyperplasia. Longitudinally, mean platelet counts significantly declined in the CFLD group (from 310 to 230 U/L, P = 0.0005). Deceased CFLD patients had lower platelet counts than those alive with CFLD (143 versus 258 U/L, P = 0.004) or those deceased with no CFLD (143 versus 327U/L, P = 0.006). CONCLUSION Adult-onset CFLD may be more prevalent than previously described, which suggests a later wave of CFLD that impacts morbidity; routine liver tests, radiologic imaging, noninvasive fibrosis markers, and FibroScan can be used algorithmically to identify adult CFLD; and further evaluation in other CF cohorts should be performed for validation. (Hepatology 2017;66:591-601).
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Affiliation(s)
- Christopher Koh
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Sasan Sakiani
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Pallavi Surana
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Xiongce Zhao
- Office of the Director, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jason Eccleston
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David E. Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - David Herion
- Department of Clinical Research Informatics, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - T. Jake Liang
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jay H. Hoofnagle
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Milica Chernick
- Office of the Director, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Klotter V, Gunchick C, Siemers E, Rath T, Hudel H, Naehrlich L, Roderfeld M, Roeb E. Assessment of pathologic increase in liver stiffness enables earlier diagnosis of CFLD: Results from a prospective longitudinal cohort study. PLoS One 2017; 12:e0178784. [PMID: 28575039 PMCID: PMC5456384 DOI: 10.1371/journal.pone.0178784] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 05/18/2017] [Indexed: 12/17/2022] Open
Abstract
About 30% of patients with Cystic Fibrosis (CF) develop CF-associated liver disease (CFLD). Recent studies have shown that transient elastography (TE), as a method to quantify liver stiffness, allows non-invasive diagnosis of CFLD in adults and children with CF. Within this study we aimed to prospectively identify patients at risk for development of CFLD by longitudinal analysis of liver stiffness and fibrosis scores in a 5-year follow-up. 36 pediatric and 16 adult patients with initial liver stiffness below the cut-off value indicative of CFLD (6.3 kPa) were examined by transient elastography for 4-5 years. TE, APRI-, and FIB-4-scores were assessed and compared by Kruskal-Wallis test and receiver operating characteristic (ROC)-analysis. Frequencies were compared by Chi2-test. Among the 36 patients participating in this study, a subgroup of 9 patients developed liver stiffness >6.3 kPa after 4-5 years with an increase of ΔTE >0.38 kPa/a (the group with increasing liver stiffness was labelled TEinc). APRI- and FIB-4 scores confirmed the rationale for grouping. The frequency of CFLD assessed by conventional diagnosis was significantly higher in TEinc-group compared to the control group (TEnorm). None of the adult CF patients matched criteria for TEinc-group. For the first time it was shown that the non-invasive longitudinal assessment of TE allows identification of patients with progression of CFLD in a subgroup of juvenile but not in adult CF patients. Comparing TE to conventional fibrosis-scores underlined the strength of the continuous assessment of liver stiffness for the exact diagnosis of progressive CFLD. The newly described cut-off for pathologic increase of liver stiffness, ΔTEcutoff = 0.38kPa/a, might enable to detect developing CFLD using consequent follow up TE measurements before reaching the level of stiffness indicating established CFLD. Nevertheless, the limited size of the analyzed cohort should encourage a prospective, multi-center, long term follow up study to confirm the suggested cut-off for the rise in liver stiffness.
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Affiliation(s)
- Victoria Klotter
- Department of Internal Medicine, Division of Gastroenterology, Justus-Liebig-University, Giessen, Germany
| | - Caroline Gunchick
- Department of Internal Medicine, Division of Gastroenterology, Justus-Liebig-University, Giessen, Germany
| | - Enno Siemers
- Department of Internal Medicine, Division of Gastroenterology, Justus-Liebig-University, Giessen, Germany
| | - Timo Rath
- Department of Medicine 1, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Helge Hudel
- Institute for Medical Informatics, Justus-Liebig-University, Giessen, Germany
| | - Lutz Naehrlich
- Department of Pediatrics, Division of Pulmonology, Justus-Liebig-University, Giessen, Germany
| | - Martin Roderfeld
- Department of Internal Medicine, Division of Gastroenterology, Justus-Liebig-University, Giessen, Germany
| | - Elke Roeb
- Department of Internal Medicine, Division of Gastroenterology, Justus-Liebig-University, Giessen, Germany
- * E-mail:
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Krzyżanowska P, Drzymała-Czyż S, Pogorzelski A, Duś-Żuchowska M, Skorupa W, Bober L, Sapiejka E, Oralewska B, Rohovyk N, Moczko J, Nowak J, Wenska-Chyży E, Rachel M, Lisowska A, Walkowiak J. Vitamin K status in cystic fibrosis patients with liver cirrhosis. Dig Liver Dis 2017; 49:672-675. [PMID: 28185838 DOI: 10.1016/j.dld.2017.01.155] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/12/2017] [Indexed: 12/11/2022]
Abstract
The available data on the influence of liver cirrhosis on vitamin K status in CF patients is scarce. Therefore, the aims of the present study were to assess the prevalence of vitamin K deficiency in cirrhotic CF subjects and to determine whether it correlates with liver cirrhosis. The study group comprised of 27 CF patients with and 63 without liver cirrhosis. Vitamin K status was assessed using prothrombin induced by vitamin K absence (PIVKA-II) and the percentage of undercarboxylated osteocalcin (u-OC). PIVKA-II concentrations were higher in cirrhotic than in non-cirrhotic CF patients (median [1st-3rd quartile]: 3.2ng/ml [1.0-10.0] vs. 1.3ng/ml [0.2-2.6], p=0.0029). However, the differences in u-OC percentages between the studied groups did not reach the level of significance (49.4% [7.0-73.8] vs. 8.0% [2.6-59.1], p=0.0501). Based on multiple linear regression analysis the dose of vitamin K and F508del mutation were potentially defined as determinants of vitamin K deficiency. Liver cirrhosis was not documented to be an independent risk factor. In CF patients with liver cirrhosis vitamin K deficiency is not only more frequent, but also more severe. However, not liver cirrhosis, but the presence of a F508del CFTR mutation constitutes an independent risk factor for vitamin K deficiency.
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Affiliation(s)
- Patrycja Krzyżanowska
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Sławomira Drzymała-Czyż
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Andrzej Pogorzelski
- Department of Pulmonology and Cystic Fibrosis, Institute of Tuberculosis and Lung Diseases, Rabka-Zdroj, Poland
| | - Monika Duś-Żuchowska
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Wojciech Skorupa
- I Department of Lung Diseases, National Institute for Tuberculosis and Lung Diseases, Warsaw, Poland
| | | | - Ewa Sapiejka
- The Specialist Centre for Medical Care of Mother and Child, Gdansk, Poland
| | - Beata Oralewska
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Jerzy Moczko
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Poznan, Poland
| | - Jan Nowak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Ewa Wenska-Chyży
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Marta Rachel
- Allergology Outpatient Department, Provincial Hospital No. 2, Rzeszow, Poland
| | - Aleksandra Lisowska
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Jarosław Walkowiak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poznan, Poland.
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Correlation of Transient Elastography With Severity of Cystic Fibrosis-related Liver Disease. J Pediatr Gastroenterol Nutr 2017; 64:505-511. [PMID: 27782957 DOI: 10.1097/mpg.0000000000001448] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The aim of the study was to evaluate whether liver stiffness measurement (LSM), determined by transient elastography, correlates with presence and severity of liver disease in children and young adults with cystic fibrosis (CF). METHODS Subjects underwent LSM at routine CF visits. Presence and severity of cystic fibrosis liver disease (CFLD) was determined by clinical parameters. Subjects were classified as no CFLD, CFLD without portal hypertension (PHTN), and CFLD with PHTN. LSM was compared with aspartate aminotransferase/platelet ratio index (APRI) as a correlate to severity of CFLD. RESULTS A total of 249 subjects (53% boys; mean age 14 ± 7 years; 7 [3%] <2 years and 74 [30%] 18-25 years) underwent LSM. Subjects were classified as 158 (64%) with no CFLD, 73 (29%) CFLD without PHTN, and 18 (7%) CFLD with PHTN. The median (interquartile range) LSM was different among the 3 groups: 4.4 (3.8-5.4), 5.1 (4.4-6.3), and 14.1 (8.8-24.8) kPa, respectively, with all pairwise comparisons different from one another (P < 0.0001). Similarly, median (interquartile range) APRI was different in groups 1 and 2 compared with CFLD with PHTN: 0.22 (0.17-0.27), 0.24 (0.17-0.33), and 0.53 (0.24-0.84), respectively (P < 0.01). Analysis of receiver operating characteristics for discriminating CFLD with PHTN from the other groups resulted in cut-points at 6.2 kPa (LSM) and 0.35 (APRI). LSM was superior to APRI in discriminating CFLD with PHTN from other groups, with areas under the curve 0.91 (LSM) versus 0.78 (APRI) (P = 0.05). CONCLUSIONS Liver stiffness, as determined by transient elastography, correlates with the presence and severity of CFLD. Although APRI provided some information regarding severity of liver disease, LSM performed better than APRI in this population.
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Abstract
Hepatic function and pulmonary function are interrelated with failure of one organ system affecting the other. With improved therapies, patients with concomitant hepatic and pulmonary failure increasingly enjoy a good quality of life and life expectancy. Therefore, the prevalence of such patients is increasing with more presenting for both emergent and elective surgical procedures. Hypoxemia requires a thorough evaluation in patients with end-stage liver disease. The most common etiologies respond to appropriate therapy. Portopulmonary hypertension and hepatopulmonary syndrome are associated with increased perioperative morbidity and mortality. It is incumbent on the anesthesiologist to understand the physiology of liver failure and its early effect on pulmonary function to ensure a successful outcome.
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Woodruff SA, Sontag MK, Accurso FJ, Sokol RJ, Narkewicz MR. Prevalence of elevated liver enzymes in children with cystic fibrosis diagnosed by newborn screen. J Cyst Fibros 2017; 16:139-145. [DOI: 10.1016/j.jcf.2016.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 08/09/2016] [Accepted: 08/09/2016] [Indexed: 10/21/2022]
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Narkewicz MR. Cystic Fibrosis Liver Disease and Ursodeoxycholic Acid: One Small Step Forward, Miles to Go. J Pediatr 2016; 177:17-18. [PMID: 27423176 DOI: 10.1016/j.jpeds.2016.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 06/07/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Michael R Narkewicz
- Department of Pediatrics Section of Pediatric Gastroenterology, Hepatology and Nutrition Children's Hospital Colorado Digestive Health Institute University of Colorado School of Medicine Aurora, Colorado.
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Relevance of 3D Cholangiography and Transient Elastography to Assess Cystic Fibrosis-Associated Liver Disease? Can Respir J 2016; 2016:4592702. [PMID: 27445541 PMCID: PMC4939173 DOI: 10.1155/2016/4592702] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 05/25/2016] [Accepted: 06/02/2016] [Indexed: 12/14/2022] Open
Abstract
Background. Cystic fibrosis-associated liver disease (CFLD) is a major cause of death. The objective of our retrospective study was to describe the relevance of magnetic resonance imaging (MRI) and liver stiffness measurement (LSM) for CFLD evaluation. Methods. All cystic fibrosis adult patients evaluated by MRI and LSM were included. MR signs of portal hypertension (PHT), dysmorphia, or cholangitis were collected and LSM expressed in kPa and Metavir. Results. Of 25 patients, 52% had abnormal MRI. Median LSM was 5.7 kPa (3.4–9.9). Three patients had F2 score and one had F3 score. In patients with PHT, LSM was 7.85 kPa (3.7–9.9) compared to 5 (3.4–7.5) in others, p = 0.02. In patients with abnormal liver function tests, 50% had increased LSM (≥F2), whereas 94% with normal tests had normal LSM (p = 0.04). Seven patients had abnormal MRI despite normal ultrasonography. Conclusions. MRI and LSM provide useful information on CFLD and may help to screen patients with PHT.
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Supplementation of ursodeoxycholic acid improves fat digestion and absorption in cystic fibrosis patients with mild liver involvement. Eur J Gastroenterol Hepatol 2016; 28:645-9. [PMID: 26882172 DOI: 10.1097/meg.0000000000000593] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Ursodeoxycholic acid (UDCA) supplementation is recommended for cystic fibrosis (CF) patients with associated liver disease. However, its effect on fat digestion and absorption is not known. MATERIALS AND METHODS In 23 patients with mild liver involvement, a C-mixed triglyceride breath test was performed on UDCA supplementation (with and without pancreatic enzymes - standard and increased dose) and after 1 month of UDCA withdrawal. Cumulative percentage dose recovery [CPDR; median (interquartile range)] has been considered to reflect lipid digestion and absorption. RESULTS The enzyme supplementation resulted in a significant CPDR improvement [0% (0-0) vs. 4.6% (0.4-6.0); P<0.00046]. With the increased dose of enzymes in 16 patients with abnormal C-mixed triglyceride breath test results and lipase dose less than 3000 U/g of fat, higher CPDR values [8.6% (5.6-12.7); P<0.000027] were observed. However, a 1-month UDCA withdrawal resulted in a significant reduction in (P<0.000031) fat digestion and absorption [2.9% (0.7-5.8)]. CONCLUSION UDCA supplementation seems to enhance lipid digestion and absorption in pancreatic insufficient CF patients with mild liver involvement. This finding points toward the potential impact of UDCA supplementation on nutritional status in CF patients with liver disease and underscores the often overlooked role of factors other than pancreatic enzymes on digestion and absorption of fats in CF.
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Spielberg DR, Clancy JP. Cystic Fibrosis and Its Management Through Established and Emerging Therapies. Annu Rev Genomics Hum Genet 2016; 17:155-75. [PMID: 26905785 DOI: 10.1146/annurev-genom-090314-050024] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cystic fibrosis (CF) is the most common life-shortening autosomal recessive disorder in the Caucasian population and occurs in many other ethnicities worldwide. The daily treatment burden is substantial for CF patients even when they are well, with numerous pharmacologic and physical therapies targeting lung disease requiring the greatest time commitment. CF treatments continue to advance with greater understanding of factors influencing long-term morbidity and mortality. In recent years, in-depth understanding of genetic and protein structure-function relationships has led to the introduction of targeted therapies for patients with specific CF genotypes. With these advances, CF has become a model of personalized or precision medicine. The near future will see greater access to targeted therapies for most patients carrying common mutations, which will mandate individualized bench-to-bedside methodologies for those with rare genotypes.
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Affiliation(s)
- David R Spielberg
- Department of Pediatrics, Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio 45229; ,
| | - John P Clancy
- Department of Pediatrics, Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio 45229; ,
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Dewulf J, Vermeulen F, Wanyama S, Thomas M, Proesmans M, Dupont L, De Boeck K. Treatment burden in patients with at least one class IV or V CFTR mutation. Pediatr Pulmonol 2015; 50:1230-6. [PMID: 26540286 DOI: 10.1002/ppul.23313] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/04/2015] [Accepted: 08/28/2015] [Indexed: 12/27/2022]
Abstract
CFTR mutations are grouped according to disease-causing mechanism. Several studies demonstrated that patients having at least one mutation of class IV/V, present with a milder phenotype, but little is known about their relative treatment burden. We compared treatment burden between patients with two class I, II, or III mutations and patients with at least one mutation of class IV/V in the 2010 database of the Belgian CF Registry. We calculated a "Treatment Burden Index" (TBI) by assigning long term therapies to categories low, medium and high intensity, for differential weighing in the total score. There were 779 patients with two known class I/II/III mutations and 94 patients with at least one class IV/V mutation. Compared to class I/II/III, class IV/V patients had a lower median number of clinic visits (4 vs. 5; P < 0.001), a lower risk of hospitalization (24.7% vs. 50.8%; P < 0.001) and intravenous antibiotic treatment (23.5% vs. 46.0%; P < 0.001) and a lower median TBI (6 vs. 9; P < 0.001). These differences remained significant when only class IV/V patients with pancreatic insufficiency (n = 31) were considered. This study clearly demonstrates the significantly lower treatment burden in patients with CF and at least one class IV/V mutation compared to patients with two class I/II/III mutations and contributes to providing better individual counseling at time of diagnosis.
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Affiliation(s)
- Jonas Dewulf
- Department of Pediatrics, University Hospitals of Leuven, Belgium
| | | | - Simeon Wanyama
- Scientific Institute of Public Health, on behalf of the Belgian CF Registry, Brussels, Belgium
| | - Muriel Thomas
- Scientific Institute of Public Health, on behalf of the Belgian CF Registry, Brussels, Belgium
| | | | - Lieven Dupont
- Department of Pulmonology, University Hospitals of Leuven, Belgium
| | - Kris De Boeck
- Department of Pediatrics, University Hospitals of Leuven, Belgium
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46
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Leung DH, Khan M, Minard CG, Guffey D, Ramm LE, Clouston AD, Miller G, Lewindon PJ, Shepherd RW, Ramm GA. Aspartate aminotransferase to platelet ratio and fibrosis-4 as biomarkers in biopsy-validated pediatric cystic fibrosis liver disease. Hepatology 2015. [PMID: 26223427 DOI: 10.1002/hep.28016] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
UNLABELLED Up to 10% of cystic fibrosis (CF) children develop cirrhosis by the first decade. We evaluated the utility of two simple biomarkers, aspartate aminotransferase to platelet ratio index (APRI) and FIB-4, in predicting degree of fibrosis in pediatric CF liver disease (CFLD) validated by liver biopsy. In this retrospective, cross-sectional study, 67 children with CFLD had dual-pass liver biopsies and 104 age- and sex-matched CF children without liver disease (CFnoLD) had serum to calculate APRI and FIB-4 collected at enrollment. CFLD was defined as having two of the following: (1) hepatomegaly±splenomegaly; (2)>6 months elevation of ALT (>1.5× upper limit of normal ULN); or (3) abnormal liver ultrasound findings. Biopsies were staged according to Metavir classification by two blinded pathologists. Receiver operating characteristic (ROC) analysis and continuation ratio logistic regression were performed to assess the predictability of these biomarkers to distinguish CFLD from CFnoLD and determine fibrosis stage-specific cut-off values. The AUC for APRI was better than FIB-4 (0.75 vs. 0.60; P=0.005) for predicting CFLD and severe CFLD (F3-F4) (0.81). An APRI score>0.264 demonstrated a sensitivity (95% confidence interval [CI]) of 73.1% (60.9, 83.2) and specificity of 70.2% (60.4, 78.8) in predicting CFLD. A 50% increase in APRI was associated with a 2.4-fold (95% CI: 1.7, 3.3) increased odds of having CFLD. APRI demonstrated full agreement with histology staging 37% of the time, but was within one stage 73% of the time. Only FIB-4 predicted portal hypertension at diagnosis (area under the receiver operator characteristic curve [AUC 0.91; P<0.001). CONCLUSION This is the first liver biopsy-validated study of APRI and FIB-4 in pediatric CFLD. APRI appears superior to FIB-4 in differentiating CFLD versus CFnoLD. APRI also exhibited a high AUC in predicting severe liver fibrosis with specific cutoffs for lower stages.
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Affiliation(s)
- Daniel H Leung
- Division of Pediatric Gastroenterology, Hepatology, Nutrition, Baylor College of Medicine, Houston, TX.,Texas Children's Liver Center, Houston, TX
| | | | - Charles G Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX
| | - Danielle Guffey
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX
| | - Louise E Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Andrew D Clouston
- Envoi Pathology and University of Queensland, Brisbane, QLD, Australia
| | - Gregory Miller
- Envoi Pathology and University of Queensland, Brisbane, QLD, Australia
| | - Peter J Lewindon
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.,Department of Gastroenterology, Royal Children's Hospital, Brisbane, QLD, Australia
| | - Ross W Shepherd
- Division of Pediatric Gastroenterology, Hepatology, Nutrition, Baylor College of Medicine, Houston, TX.,Texas Children's Liver Center, Houston, TX.,Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Grant A Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.,Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
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47
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Leung DH, Ye W, Molleston JP, Weymann A, Ling S, Paranjape SM, Romero R, Schwarzenberg SJ, Palermo J, Alonso EM, Murray KF, Marshall BC, Sherker AH, Siegel MJ, Krishnamurthy R, Harned R, Karmazyn B, Magee JC, Narkewicz MR. Baseline Ultrasound and Clinical Correlates in Children with Cystic Fibrosis. J Pediatr 2015; 167:862-868.e2. [PMID: 26254836 PMCID: PMC4586395 DOI: 10.1016/j.jpeds.2015.06.062] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 05/18/2015] [Accepted: 06/26/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate the relationship between abdominal ultrasound findings and demographic, historical, and clinical features in children with cystic fibrosis (CF). STUDY DESIGN Children age 3-12 years with CF without known cirrhosis, were enrolled in a prospective, multicenter study of ultrasound to predict hepatic fibrosis. Consensus ultrasound patterns were assigned by 3 radiologists as normal, heterogeneous, homogeneous, or cirrhosis. Data were derived from direct collection and US or Toronto CF registries. χ(2) or ANOVA were used to compare variables among ultrasound groups and between normal and abnormal. Logistic regression was used to study risk factors for having abnormal ultrasound. RESULTS Findings in 719 subjects were normal (n = 590, 82.1%), heterogeneous (64, 8.9%), homogeneous (41, 5.7%), and cirrhosis (24, 3.3%). Cirrhosis (P = .0004), homogeneous (P < .0001), and heterogeneous (P = .03) were older than normal. More males were heterogeneous (P = .001). More heterogeneous (15.0%, P = .009) and cirrhosis (25.0%, P = .005) had CF-related diabetes or impaired glucose tolerance vs normal (5.4%). Early infection with Pseudomonas aeruginosa (<2 years old) was associated with a lower risk (OR 0.42, P = .0007) of abnormal. Ursodeoxycholic acid use (OR 3.69, P < .0001) and CF-related diabetes (OR 2.21, P = .019) were associated with increased risk of abnormal. CONCLUSIONS Unsuspected cirrhosis is seen in 3.3% of young patients with CF, heterogeneous in 8.9%. Abnormal ultrasound is associated with CF-related diabetes, and early P aeruginosa is associated with normal ultrasound. Prospective assessment of these risk factors may identify potential interventional targets. TRIAL REGISTRATION ClinicalTrials.gov: NCT01144507.
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Affiliation(s)
- Daniel H Leung
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine/Texas Children's Hospital, Houston, TX.
| | - Wen Ye
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine Riley Hospital for Children, Indianapolis, IN
| | - Alexander Weymann
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Simon Ling
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Shruti M Paranjape
- Division of Pediatric Pulmonology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rene Romero
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Atlanta, GA
| | - Sara Jane Schwarzenberg
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Joseph Palermo
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Estella M Alonso
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann and Robert Lurie Children's Hospital, Chicago, IL
| | - Karen F Murray
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital and University of Washington, Seattle, WA
| | | | - Averell H Sherker
- Liver Diseases Research Branch, Division of Digestive Diseases and Nutrition, NIDDK, Bethesda, MD
| | - Marilyn J Siegel
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Rajesh Krishnamurthy
- EB Singleton Department of Diagnostic Imaging, Texas Children's Hospital, Houston, TX
| | - Roger Harned
- Department of Radiology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Boaz Karmazyn
- Pediatric Radiology, Riley Hospital for Children, Indianapolis, IN
| | - John C Magee
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Michael R Narkewicz
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado SOM and Children's Hospital Colorado, Aurora, CO.
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48
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What Is the Role of Nutrition Therapy in the Management of the Adult Cystic Fibrosis Patient? Curr Nutr Rep 2015. [DOI: 10.1007/s13668-015-0136-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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49
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Kelly T, Buxbaum J. Gastrointestinal Manifestations of Cystic Fibrosis. Dig Dis Sci 2015; 60:1903-13. [PMID: 25648641 DOI: 10.1007/s10620-015-3546-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/19/2015] [Indexed: 12/27/2022]
Abstract
Gastrointestinal symptoms of cystic fibrosis are the most important non-pulmonary manifestations of this genetic illness. Pancreatic manifestations include acute and chronic pancreatitis as well as pancreas insufficiency resulting in malnutrition. Complications in the gastrointestinal lumen are diverse and include distal intestinal obstruction syndrome (DIOS), meconium ileus, intussusception, and constipation; biliary tract complications include focal biliary cirrhosis and cholangiectasis. The common pathophysiology is the inspissation of secretions in the hollow structures of the gastrointestinal tract. Improved survival of CF patients mandates that the adult gastroenterologist be aware of the presentation and treatment of pancreatic, luminal, and hepatobiliary CF complications.
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Affiliation(s)
- Thomas Kelly
- Division of Gastroenterology and Liver Diseases, Los Angeles County Hospital, Keck School of Medicine, The University of Southern California, D & T Building Room B4H100, 1983 Marengo St, Los Angeles, CA, 90033-1370, USA
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50
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Buxbaum J, Nguyen N, Kulkarni S, Palmer S, Rao A, Selby R. Multidisciplinary Treatment of Cystic Fibrosis-Related Recurrent Pyogenic Cholangitis (CF-RPC). Dig Dis Sci 2015; 60:1801-4. [PMID: 25630419 DOI: 10.1007/s10620-015-3532-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/07/2015] [Indexed: 12/09/2022]
Abstract
BACKGROUND As the survival of cystic fibrosis patients improves due to better treatment of its pulmonary manifestations, the management of hepatobiliary complications becomes increasingly vital. While focal biliary cirrhosis is common, large duct manifestations are less frequently encountered. METHODS We prospectively evaluated cases of large bile duct disease in a large adult cystic fibrosis practice at the Keck Hospital of the University of Southern California. RESULTS Over a 5-year period, six patients presented with cholangiectasia, hepatolithiasis, and strictures. Their clinical presentation and course closely resembled recurrent pyogenic cholangitis (RPC). Treatment of cholangitis and strictures was primarily by endoscopic retrograde cholangiopancreatography, but major hepatobiliary surgery following pulmonary optimization was required in 33 %. CONCLUSION In adult populations, CF-RPC may not be as unusual as previously reported and recognition allows optimal endoscopic, medical, and surgical management.
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Affiliation(s)
- James Buxbaum
- Department of Medicine, Los Angeles County Hospital, Keck School of Medicine, University of Southern California, D & T Building Room B4H100, 1983 Marengo St., Los Angeles, CA, 90033-1370, USA,
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