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Pinon M, Kamath BM. What's new in pediatric genetic cholestatic liver disease: advances in etiology, diagnostics and therapeutic approaches. Curr Opin Pediatr 2024; 36:524-536. [PMID: 38957097 DOI: 10.1097/mop.0000000000001380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW To highlight recent advances in pediatric cholestatic liver disease, including promising novel prognostic markers and new therapies. FINDINGS Additional genetic variants associated with the progressive familial intrahepatic cholestasis (PFIC) phenotype and new genetic cholangiopathies, with an emerging role of ciliopathy genes, are increasingly being identified. Genotype severity predicts outcomes in bile salt export pump (BSEP) deficiency, and post-biliary diversion serum bile acid levels significantly affect native liver survival in BSEP and progressive familial intrahepatic cholestasis type 1 (FIC1 deficiency) patients. Heterozygous variants in the MDR3 gene have been associated with various cholestatic liver disease phenotypes in adults. Ileal bile acid transporter (IBAT) inhibitors, approved for pruritus in PFIC and Alagille Syndrome (ALGS), have been associated with improved long-term quality of life and event-free survival. SUMMARY Next-generation sequencing (NGS) technologies have revolutionized diagnostic approaches, while discovery of new intracellular signaling pathways show promise in identifying therapeutic targets and personalized strategies. Bile acids may play a significant role in hepatic damage progression, suggesting their monitoring could guide cholestatic liver disease management. IBAT inhibitors should be incorporated early into routine management algorithms for pruritus. Data are emerging as to whether IBAT inhibitors are impacting disease biology and modifying the natural history of the cholestasis.
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Affiliation(s)
- Michele Pinon
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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2
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Palle SK, Leung DH. Advanced cystic fibrosis liver disease: Endovascular, endoscopic, radiologic, and surgical considerations. Pediatr Pulmonol 2024; 59 Suppl 1:S115-S122. [PMID: 39105344 DOI: 10.1002/ppul.27174] [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: 08/15/2023] [Revised: 06/29/2024] [Accepted: 07/03/2024] [Indexed: 08/07/2024]
Abstract
Up to 90% of people with CF (pwCF) will have some form of hepatobiliary involvement. This manuscript aims to explore the different endovascular, endoscopic, radiological and surgical procedures available to diagnose and manage the most severe form of CF hepatobiliary involvement (CFHBI) known as advanced cystic fibrosis liver disease (aCFLD), seen in 10% of pwCF. These procedures and interventions include liver biopsy, hepatic venous pressure gradient measurement, gastrostomy tube placement to optimize nutrition, paracentesis, endoscopic variceal control of bleeding and portosystemic shunting before liver transplantation. By utilizing advanced diagnostic or surgical techniques, healthcare professionals of pwCF can more effectively manage patients with CFHBI and aCFLD and potentially improve patient outcomes.
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Affiliation(s)
- Sirish K Palle
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
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3
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Marques LS, Firmida MC, Marson FAL. Were deaths recorded in Brazil due to cystic fibrosis or pulmonary fibrosis? A data-based analysis. Front Med (Lausanne) 2024; 11:1459785. [PMID: 39253539 PMCID: PMC11382496 DOI: 10.3389/fmed.2024.1459785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 07/29/2024] [Indexed: 09/11/2024] Open
Affiliation(s)
- Leonardo Souza Marques
- Laboratory of Molecular Biology and Genetics, University of São Francisco, Bragança Paulista, São Paulo, Brazil
- Laboratory of Clinical and Molecular Microbiology, University of São Francisco, Bragança Paulista, São Paulo, Brazil
- LunGuardian Research Group-Epidemiology of Respiratory and Infectious Diseases, University of São Francisco, Bragança Paulista, São Paulo, Brazil
| | - Mônica Cássia Firmida
- LunGuardian Research Group-Epidemiology of Respiratory and Infectious Diseases, University of São Francisco, Bragança Paulista, São Paulo, Brazil
- Department of Integrated Medical Sciences, University of the State of Rio de Janeiro, Cabo Frio, Rio de Janeiro, Brazil
| | - Fernando Augusto Lima Marson
- Laboratory of Molecular Biology and Genetics, University of São Francisco, Bragança Paulista, São Paulo, Brazil
- Laboratory of Clinical and Molecular Microbiology, University of São Francisco, Bragança Paulista, São Paulo, Brazil
- LunGuardian Research Group-Epidemiology of Respiratory and Infectious Diseases, University of São Francisco, Bragança Paulista, São Paulo, Brazil
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4
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Mall MA, Burgel PR, Castellani C, Davies JC, Salathe M, Taylor-Cousar JL. Cystic fibrosis. Nat Rev Dis Primers 2024; 10:53. [PMID: 39117676 DOI: 10.1038/s41572-024-00538-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2024] [Indexed: 08/10/2024]
Abstract
Cystic fibrosis is a rare genetic disease caused by mutations in CFTR, the gene encoding cystic fibrosis transmembrane conductance regulator (CFTR). The discovery of CFTR in 1989 has enabled the unravelling of disease mechanisms and, more recently, the development of CFTR-directed therapeutics that target the underlying molecular defect. The CFTR protein functions as an ion channel that is crucial for correct ion and fluid transport across epithelial cells lining the airways and other organs. Consequently, CFTR dysfunction causes a complex multi-organ disease but, to date, most of the morbidity and mortality in people with cystic fibrosis is due to muco-obstructive lung disease. Cystic fibrosis care has long been limited to treating symptoms using nutritional support, airway clearance techniques and antibiotics to suppress airway infection. The widespread implementation of newborn screening for cystic fibrosis and the introduction of a highly effective triple combination CFTR modulator therapy that has unprecedented clinical benefits in up to 90% of genetically eligible people with cystic fibrosis has fundamentally changed the therapeutic landscape and improved prognosis. However, people with cystic fibrosis who are not eligible based on their CFTR genotype or who live in countries where they do not have access to this breakthrough therapy remain with a high unmet medical need.
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Affiliation(s)
- Marcus A Mall
- Department of Paediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität, Berlin, Germany.
- German Centre for Lung Research (DZL), Associated Partner Site Berlin, Berlin, Germany.
- German Center for Child and Adolescent Health (DZKJ), Partner Site Berlin, Berlin, Germany.
| | - Pierre-Régis Burgel
- Université Paris Cité and Institut Cochin, Inserm U1016, Paris, France
- Department of Respiratory Medicine and National Reference Center for Cystic Fibrosis, Cochin Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Paris, France
| | - Carlo Castellani
- IRCCS Istituto Giannina Gaslini, Cystic Fibrosis Center, Genoa, Italy
| | - Jane C Davies
- National Heart & Lung Institute, Imperial College London, London, UK
- St Thomas' NHS Trust, London, UK
- Royal Brompton Hospital, Part of Guy's & St Thomas' Trust, London, UK
| | - Matthias Salathe
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO, USA
| | - Jennifer L Taylor-Cousar
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
- Division of Pulmonary Sciences and Critical Care Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
- Division of Paediatric Pulmonary Medicine, National Jewish Health, Denver, CO, USA
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5
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Wood W, Tinich T, Lazar L, Schooler GR, Sathe M. Cystic fibrosis hepatobiliary involvement: an update on imaging in diagnosis and monitoring. Pediatr Radiol 2024; 54:1416-1427. [PMID: 39039200 DOI: 10.1007/s00247-024-05979-5] [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: 03/04/2024] [Revised: 06/16/2024] [Accepted: 06/19/2024] [Indexed: 07/24/2024]
Abstract
Analysis of the liver using imaging for persons with cystic fibrosis (CF) continues to evolve as new medical therapies are developed improving and extending life. In the 2010s, therapies targeted at modulating protein folding became available to those with CF. Therapeutic options have continued to expand, now providing both correction of protein folding and stabilization for most gene mutations that code for the CF transmembrane receptor protein (CFTR). Today, approximately 80% of persons with CF are eligible for highly effective modulator therapy. With these advancements, the impact of CF on the liver has become more complex, adding metabolism of CFTR modulators to intrinsic CF hepatobiliary involvement (CFHBI) and adding not previously appreciated vascular changes within the liver due to increased longevity in persons with CF. A combination of serum biomarkers and imaging is needed to add clarity to the diagnosis and monitoring of the severity of liver disease. A substantial portion of persons with CF will develop at least CFHBI and a subset will develop advanced cystic fibrosis-associated liver disease (aCFLD); therefore, diagnosis and monitoring need to begin in childhood. In this review, we cover the use of and need for imaging, including elastography, ultrasound, and magnetic resonance imaging (MRI), in diagnosing and monitoring CFHBI and its associated complications.
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Affiliation(s)
- William Wood
- Pediatric Residency, Department of Pediatrics, University of Texas Southwestern/Children's Health, Dallas, TX, USA
| | - Treiy Tinich
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Lauren Lazar
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Texas Southwestern Medical Center/Children's Health, Dallas, TX, 75390-9063, USA
| | - Gary R Schooler
- Department of Radiology, University of Texas Southwestern/Children's Health, Dallas, TX, USA
| | - Meghana Sathe
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Texas Southwestern Medical Center/Children's Health, Dallas, TX, 75390-9063, USA.
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6
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Castaldo A, Iacotucci P, Bagnasco S, Fevola C, Carnovale V, Antonelli F, Cernera G, Gelzo M, Terlizzi V. Liver biochemical indexes and cholesterol metabolism in cystic fibrosis patients with F508del/CFTR variant genotype after elexacaftor/tezacaftor/ivacaftor treatment. Sci Rep 2024; 14:17422. [PMID: 39075279 PMCID: PMC11286749 DOI: 10.1038/s41598-024-68511-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 07/24/2024] [Indexed: 07/31/2024] Open
Abstract
Modulators of cystic fibrosis transmembrane conductance regulator (CFTR) improved cystic fibrosis (CF) patients' outcome. The elexacaftor/tezacaftor/ivacaftor (ETI) combination was safe and effective improving lung function in patients with different CFTR genotypes, including at least one F508del mutation. However, cases with liver damage were reported. We describe 105 CF patients heterozygous for F508del in trans with another CFTR mutation, treated for 1 year with ETI. We analyzed liver biochemical parameters and cholesterol metabolism, including lathosterol and phytosterols, surrogate markers of cholesterol de-novo synthesis and absorption, respectively. The treatment significantly improved sweat chloride, body mass index and forced expiratory volume in 1 s, whereas it caused a significant increase of total and conjugated bilirubin, ALT and GGT, even if no patients developed CF liver disease. Such alterations were less relevant than those previously observed in ETI-treated F508del homozygous patients. Furthermore, ETI treatment significantly increased serum cholesterol by enhancing its absorption (correlation between serum cholesterol and phytosterols). Whereas, we observed a normalization of de-novo biosynthesis (lathosterol reduction) that was not observed in homozygous patients. These data suggest that the second mutation in trans with the F508del contributes to reduce the liver cholesterol accumulation and thus, the triggering of liver inflammation. However, no differences in the alteration of biochemical indexes were observed between CF patients with and without liver steatosis, and between patients with different mutations in trans with the F508del. Such data suggest to further investigate the effects of ETI therapy on liver function indexes and new predictive biomarkers.
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Affiliation(s)
- Alice Castaldo
- Dipartimento di Scienze Mediche Traslazionali, Sezione di Pediatria, Università di Napoli Federico II, Naples, Italy
- SC di Pneumologia e UTSIR, AORN Santobono-Pausilipon, Naples, Italy
- CEINGE-Biotecnologie Avanzate Franco Salvatore, Naples, Italy
- Dipartimento di Pediatria, Azienda Ospedaliera Universitaria Meyer IRCCS, Centro Regionale Toscano per la cura della Fibrosi Cistica, Florence, Italy
| | - Paola Iacotucci
- Dipartimento di Medicina Clinica e Chirurgia, Università di Napoli Federico II, Naples, Italy
| | - Sveva Bagnasco
- CEINGE-Biotecnologie Avanzate Franco Salvatore, Naples, Italy
| | - Cristina Fevola
- Dipartimento di Pediatria, Azienda Ospedaliera Universitaria Meyer IRCCS, Centro Regionale Toscano per la cura della Fibrosi Cistica, Florence, Italy
| | - Vincenzo Carnovale
- Dipartimento di Scienze Mediche Traslazionali, Centro di Fibrosi Cistica dell'Adulto, Università di Napoli Federico II, Naples, Italy
| | - Fabio Antonelli
- SC di Pneumologia e UTSIR, AORN Santobono-Pausilipon, Naples, Italy
| | - Gustavo Cernera
- CEINGE-Biotecnologie Avanzate Franco Salvatore, Naples, Italy
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Naples, Italy
| | - Monica Gelzo
- CEINGE-Biotecnologie Avanzate Franco Salvatore, Naples, Italy.
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Naples, Italy.
| | - Vito Terlizzi
- Dipartimento di Pediatria, Azienda Ospedaliera Universitaria Meyer IRCCS, Centro Regionale Toscano per la cura della Fibrosi Cistica, Florence, Italy
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7
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Swetland DV, Savant AP. Cystic fibrosis year in review 2023. Pediatr Pulmonol 2024. [PMID: 39056532 DOI: 10.1002/ppul.27190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 06/23/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024]
Abstract
This past year, there were many important advances for patients with cystic fibrosis (CF). Of the many publications related to CF in 2023, there was further evaluation of highly effective modulator therapy, new assessments and guidelines for clinical manifestations and therapies for CF, advances in newborn screening and diagnosis, and evaluation of outcomes for people with CF transmembrane conductance regulator-related metabolic syndrome/CF screen positive, inconclusive diagnosis. The aim of this review article is not to provide a full assessment of the wide range of articles published in 2023, but to provide a brief review of publication that may lead to changes in clinical care.
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Affiliation(s)
- David V Swetland
- Department of Pediatrics, Children's Hospital of New Orleans, New Orleans, Louisiana, USA
- Department of Pediatrics, Tulane University, New Orleans, Louisiana, USA
| | - Adrienne P Savant
- Department of Pediatrics, Children's Hospital of New Orleans, New Orleans, Louisiana, USA
- Department of Pediatrics, Tulane University, New Orleans, Louisiana, USA
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Terlizzi V, Fevola C, Presti S, Castaldo A, Daccò V, Claut L, Sepe A, Majo F, Casciaro R, Esposito I, Vitullo P, Salvi M, Troiani P, Ficili F, Parisi GF, Pantano S, Costa S, Leonetti G, Palladino N, Taccetti G, Bonomi P, Salvatore D. Reported Adverse Events in a Multicenter Cohort of Patients Ages 6-18 Years with Cystic Fibrosis and at Least One F508del Allele Receiving Elexacaftor/Tezacaftor/Ivacaftor. J Pediatr 2024; 274:114176. [PMID: 38945446 DOI: 10.1016/j.jpeds.2024.114176] [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: 01/29/2024] [Revised: 05/21/2024] [Accepted: 06/24/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE The objective of this study was to describe reported adverse events (AEs) associated with elexacaftor/tezacaftor/ivacaftor (ETI) in a pediatric sample with cystic fibrosis (CF) aged 6-18 years, with at least one F508del variant, followed at multiple Italian CF centers. STUDY DESIGN This was a retrospective, multicenter, observational study. All children receiving ETI therapy from October 2019 to December 2023 were included. We assessed the prevalence and type of any reported potential drug-related AEs, regardless of discontinuation necessity. Persistent AEs were defined as those continuing at the end of the observation period. RESULTS Among 608 patients on ETI, 109 (17.9%) reported at least 1 AE. The majority (n = 85, 77.9%) were temporary, with a median duration of 11 days (range 1-441 days). Only 7 (1.1%) patients permanently discontinued treatment, suggesting good overall safety of ETI. The most common AEs leading to discontinuation were transaminase elevations (temporary 14.1%, persistent 25.9%) and urticaria (temporary 41.2%, persistent 7.4%). Creatinine phosphokinase elevation was uncommon. No significant differences in AEs were observed based on sex, age groups (6-11 vs 12-18 years), or genotype. Pre-existing CF-related liver disease was associated with an increased risk of transaminase elevations. We identified significant variability in the percentage of reported AEs (ANOVA P value .026). CONCLUSIONS This real-world study highlights significant variability in reported AEs. Our findings suggest that ETI is a safe and well-tolerated therapy in children and adolescents with CF. However, further long-term safety and effectiveness investigations are warranted.
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Affiliation(s)
- Vito Terlizzi
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Florence, Italy.
| | - Cristina Fevola
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Florence, Italy
| | - Santiago Presti
- Pediatric Respiratory Unit, Department of Clinical and Experimental Medicine, San Marco Hospital, University of Catania, Catania, Italy
| | - Alice Castaldo
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Florence, Italy; SC di Pneumologia e UTSIR, AORN Santobono-Pausilipon, Naples, Italy; Paediatric Unit, Department of Translational Medical Sciences, Cystic Fibrosis Regional Reference Center, University of Naples Federico II, Naples, Italy
| | - Valeria Daccò
- Department of Pathophysiology and Transplantation, Cystic Fibrosis Regional Reference Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Laura Claut
- Department of Pathophysiology and Transplantation, Cystic Fibrosis Regional Reference Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Angela Sepe
- Paediatric Unit, Department of Translational Medical Sciences, Cystic Fibrosis Regional Reference Center, University of Naples Federico II, Naples, Italy
| | - Fabio Majo
- Cystic Fibrosis Centre, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rosaria Casciaro
- Department of Pediatrics, IRCCS Institute "Giannina Gaslini", Cystic Fibrosis Centre, Genoa, Italy
| | - Irene Esposito
- Paediatric Pulmonology Unit, Regina Margherita Hospital AOU Città della Salute e della Scienza, Torino, Italy
| | - Pamela Vitullo
- Cystic Fibrosis Support Center, Ospedale G. Tatarella di Cerignola, Cerignola, Italy
| | - Marta Salvi
- Department of Pediatrics, Cystic Fibrosis Regional Support Center, ASST Spedali Civili Brescia, University of Brescia, Brescia, Italy
| | - Patrizia Troiani
- Lazio Reference Center for Cystic Fibrosis, Policlinico Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Francesca Ficili
- Cystic Fibrosis Center, Ospedale Giovanni Di Cristina, Palermo, Italy
| | - Giuseppe Fabio Parisi
- Pediatric Respiratory Unit, Department of Clinical and Experimental Medicine, San Marco Hospital, University of Catania, Catania, Italy
| | - Stefano Pantano
- U.O.S.D. C.R.R. Fibrosi Cistica Ospedale "San Liberatore" di Atri-Dipartimento Materno Infantile-ASL Teramo, Teramo, Italy
| | - Stefano Costa
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Policlinico G. Martino Hospital, University of Messina, Messina, Italy
| | - Giuseppina Leonetti
- Pediatric Cystic Fibrosis Centre, Azienda Universitaria Ospedaliera Consorziale Policlinico, Bari, Italy
| | - Nicola Palladino
- Cystic Fibrosis Center of Umbria Region, Branca Hospital, Branca, Italy
| | - Giovanni Taccetti
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Florence, Italy
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Albaiz FA, Semenchuk J, Ma X, Lightfoot D, Gonska T, Tullis E, Stephenson AL. Clinical outcomes after liver transplant in people with cystic fibrosis: A systematic review and meta-analysis. J Cyst Fibros 2024:S1569-1993(24)00781-1. [PMID: 38942722 DOI: 10.1016/j.jcf.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 06/21/2024] [Accepted: 06/22/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Data on the impact of liver transplantation (LT) in cystic fibrosis (CF) on lung function and exacerbations are limited. The objective of this study was to summarize the literature on lung function, nutritional status, survival, and complications following LT in people with CF. METHODS Three databases were searched until September 2023, to identify the impact of LT in CF. Lung transplant prior to LT and simultaneous liver-lung transplant were excluded. Pooled hazard ratios were calculated using random-effects models. RESULTS Thirty studies were included in this review, with 3 and 9 studies included in meta-analyses for nutritional status and lung function, respectively. Eighty-three percent of the studies used data that was more than a decade old. There was a significant increase in percent-predicted forced expiratory volume with mean change of 7.16 % (2.13, 12.19; p = 0.005) one year post-LT. Pulmonary exacerbations decreased in the short-term, however there was no significant change in body mass index (BMI). One-year survival post-LT ranged between 75 and 100 %, while five-year survival was lower at 64-89 %. CONCLUSION Existing data suggest that LT improves lung function in the short term and does not increase the likelihood of pulmonary exacerbations, despite ongoing immunosuppression in the setting of chronic lung infection.
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Affiliation(s)
- Faisal A Albaiz
- Division of Respirology, St. Michael's Hospital, University of Toronto, Ontario, Canada; Organ Transplant Centre of Excellence, Lung Health Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Julie Semenchuk
- Division of Respirology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Xiayi Ma
- Division of Respirology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - David Lightfoot
- St Michael's Health Sciences Library, St Michael's Hospital, Toronto, Ontario, Canada
| | - Tanja Gonska
- The Hospital for Sick Children, Division of Gastroenterology, Toronto, Ontario, Canada
| | - Elizabeth Tullis
- Division of Respirology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Anne L Stephenson
- Division of Respirology, St. Michael's Hospital, University of Toronto, Ontario, Canada.
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10
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Eldredge JA, Oliver MR, Ooi CY. Cystic fibrosis liver disease in the new era of cystic fibrosis transmembrane conductance regulator (CFTR) modulators. Paediatr Respir Rev 2024; 50:54-61. [PMID: 38281822 DOI: 10.1016/j.prrv.2023.12.005] [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: 12/21/2023] [Accepted: 12/21/2023] [Indexed: 01/30/2024]
Abstract
Cystic fibrosis liver disease (CFLD) is characterised by a wide heterogenity of manifestations and severity. It represents a major cause of morbidity in people with cystic fibrosis (PwCF), which will be of increasing relevance as survival increases in the new era of cystic fibrosis care. No medical therapy currently available has evidence to treat or prevent progression of liver disease. Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) modulators may be transformative on pulmonary, nutritional and quality of life, but direct effect on long term liver disease outcomes is not yet established. Drug-associated hepatic adverse effects may be common, and clinician familiarity with drug-monitoring recommendations is essential. Longitudinal studies are required to understand the effect of CFTR modulators on the incidence and natural history of CFLD, including with early treatment initiation, in established advanced liver disease, and post liver transplantation.
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Affiliation(s)
- Jessica A Eldredge
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Australia.
| | - Mark R Oliver
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Australia.
| | - Chee Y Ooi
- Department of Gastroenterology, Sydney Children's Hospital Randwick, NSW, Australia; School of Clinical Medicine, Discipline of Paediatrics and Child Health, UNSW Medicine & Health, University of New South Wales, Sydney, Australia.
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11
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Chun SW, Somers ME, Burgener EB. Highly effective cystic fibrosis transmembrane conductance (regulator) modulator therapy: shifting the curve for most while leaving some further behind. Curr Opin Pediatr 2024; 36:290-295. [PMID: 38411576 PMCID: PMC11042992 DOI: 10.1097/mop.0000000000001338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW Traditional cystic fibrosis (CF) care had been focused on early intervention and symptom mitigation. With the advent of highly effective cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy (HEMT), in particular, the approval of elexacaftor/tezacaftor/ivacaftor in 2019, there has been a dramatic improvement in outcomes in CF. The purpose of this article is to review the benefits, limitations, and impact of HEMT as well as discuss the new implications, challenges, and hope that modulators bring to people with CF (pwCF). RECENT FINDINGS HEMT has demonstrated sustained improvement in lung function, nutrition, quality of life, and survival for over 90% of pwCF. As HEMT has delivered such promise, there is a small but significant portion of pwCF who do not benefit from HEMT due to ineligible mutations, intolerance, or lack of accessibility to modulators. SUMMARY HEMT has significantly improved outcomes, but continued research is needed to understand the new challenges and implications the era of HEMT will bring, as well as how to provide equitable care to those who are unable to benefit from HEMT.
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Affiliation(s)
- Stanford W Chun
- Division of Pediatric Pulmonology & Sleep Medicine, Department of Pediatrics, Children’s Hospital of Los Angeles, Keck School of Medicine at University of Southern California, Los Angeles, CA
| | - Maya E Somers
- Division of Infectious Disease & Geographic Medicine, Department of Medicine, Stanford University, Stanford, CA
| | - Elizabeth B Burgener
- Division of Pediatric Pulmonology & Sleep Medicine, Department of Pediatrics, Children’s Hospital of Los Angeles, Keck School of Medicine at University of Southern California, Los Angeles, CA
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12
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Colombo C, Lanfranchi C, Tosetti G, Corti F, Primignani M. Management of liver disease and portal hypertension in cystic fibrosis: a review. Expert Rev Respir Med 2024; 18:269-281. [PMID: 38962827 DOI: 10.1080/17476348.2024.2365842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 06/05/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION Cystic fibrosis (CF)-associated liver disease can significantly affect the quality of life and survival of people with CF. The hepatobiliary manifestations in CF are various, with focal/multilobular biliary cirrhosis more common in children and porto-sinusoidal vascular disease (PSVD) in young adults. Portal hypertensive complications, particularly bleeding from esophagogastric varices and hypersplenism are common, while liver failure is rarer and mainly linked to biliary disease. AREAS COVERED This review explores current therapeutic options for CF-associated liver disease, presenting ongoing studies and new insights into parthenogenesis for potential future therapies. EXPERT OPINION Monitoring for signs of portal hypertension is essential. Limited evidence supports ursodeoxycholic acid (UDCA) efficacy in halting CF liver disease progression. The effect of cystic fibrosis transmembrane conductance regulator (CFTR) modulators on liver outcomes lacks definitive data, since patients with CF-related liver disease were excluded from trials due to potential hepatotoxicity. A proposed approach involves using UDCA and modulators in early stages, along with anti-inflammatory agents, with further therapeutic strategies awaiting randomized trials. Prevention of portal hypertensive bleeding includes endoscopic sclerotherapy or ligation of esophageal varices. Nonselective beta-blockers may also prevent bleeding and could be cautiously implemented. Other non-etiological treatments require investigation.
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Affiliation(s)
- Carla Colombo
- Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Chiara Lanfranchi
- Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giulia Tosetti
- Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabiola Corti
- Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Massimo Primignani
- Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Protich HE, Molleston JP, Bozic M, Pettit RS. Elexacaftor/Tezacaftor/Ivacaftor use in Pediatric Cystic Fibrosis Patients with Advanced Liver Disease. J Cyst Fibros 2024:S1569-1993(24)00040-7. [PMID: 38580564 DOI: 10.1016/j.jcf.2024.03.011] [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: 10/29/2023] [Revised: 02/29/2024] [Accepted: 03/19/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy extends the life expectancy of people with cystic fibrosis (PwCF). However, CFTR modulators have not been well studied in patients with cystic fibrosis liver disease (CFLD), specifically those with advanced liver disease with portal hypertension. The purpose of this report is to describe the use of elexacaftor/tezacaftor/ivacaftor (ETI) in pediatric CF patients with advanced CFLD. METHODS This retrospective case series included PwCF < 18 years old with baseline advanced CFLD initiated on ETI. RESULTS Eleven PwCF and advanced CFLD were treated with ETI; six started a reduced dose regimen. No patient required treatment interruption and four patients received dose changes related to increase in transaminase and/or bilirubin elevations. Mean (SD) change in ppFEV1 from prior to ETI to highest value during therapy was 14.27 % (4.25) (p = 0.007). When evaluating the group as whole, AST decreased from baseline to last reported -15.18 (23.23) units/L (p = 0.054) and ALT slightly increased 0.73 (39.13) units/L (p = 0.96). Bilirubin increased minimally overall for patients with mean change from baseline of 0.83 (1.33) mg/dL [range -0.5-3] (p = 0.17). A model for time on ETI showed a significant decrease in AST over time of 0.955 per month of ETI but no other liver biochemistries were significant. No patient experienced decompensation of CFLD. CONCLUSION ETI therapy in pediatric CF patients with advanced CFLD can be beneficial in improving pulmonary and nutritional outcomes without negative impact on liver biochemistries or hepatic outcomes. Close monitoring is recommended to ensure safety and tolerability.
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Affiliation(s)
- Hannah E Protich
- Department of Pharmacy, Riley Hospital for Children at IU Health, 705 Riley Hospital Drive, Simon Family Tower W6111, Indianapolis, IN, USA.
| | - Jean P Molleston
- Department of Pediatric Gastroenterology, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 4210, Indianapolis, Indiana, USA
| | - Molly Bozic
- Department of Pediatric Gastroenterology, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 4210, Indianapolis, Indiana, USA
| | - Rebecca S Pettit
- Department of Pharmacy, Riley Hospital for Children at IU Health, 705 Riley Hospital Drive, Simon Family Tower W6111, Indianapolis, IN, USA
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McDonald CM, Reid EK, Pohl JF, Yuzyuk TK, Padula LM, Vavrina K, Altman K. Cystic fibrosis and fat malabsorption: Pathophysiology of the cystic fibrosis gastrointestinal tract and the impact of highly effective CFTR modulator therapy. Nutr Clin Pract 2024; 39 Suppl 1:S57-S77. [PMID: 38429959 DOI: 10.1002/ncp.11122] [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: 09/28/2023] [Revised: 11/28/2023] [Accepted: 12/28/2023] [Indexed: 03/03/2024] Open
Abstract
Cystic fibrosis (CF) is a progressive, genetic, multi-organ disease affecting the respiratory, digestive, endocrine, and reproductive systems. CF can affect any aspect of the gastrointestinal (GI) tract, including the esophagus, stomach, small intestine, colon, pancreas, liver, and gall bladder. GI pathophysiology associated with CF results from CF membrane conductance regulator (CFTR) dysfunction. The majority of people with CF (pwCF) experience exocrine pancreatic insufficiency resulting in malabsorption of nutrients and malnutrition. Additionally, other factors can cause or worsen fat malabsorption, including the potential for short gut syndrome with a history of meconium ileus, hepatobiliary diseases, and disrupted intraluminal factors, such as inadequate bile salts, abnormal pH, intestinal microbiome changes, and small intestinal bacterial overgrowth. Signs and symptoms associated with fat malabsorption, such as abdominal pain, bloating, malodorous flatus, gastroesophageal reflux, nausea, anorexia, steatorrhea, constipation, and distal intestinal obstruction syndrome, are seen in pwCF despite the use of pancreatic enzyme replacement therapy. Given the association of poor nutrition status with lung function decline and increased mortality, aggressive nutrition support is essential in CF care to optimize growth in children and to achieve and maintain a healthy body mass index in adults. The introduction of highly effective CFTR modulator therapy and other advances in CF care have profoundly changed the course of CF management. However, GI symptoms in some pwCF may persist. The use of current knowledge of the pathophysiology of the CF GI tract as well as appropriate, individualized management of GI symptoms continue to be integral components of care for pwCF.
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Affiliation(s)
| | - Elizabeth K Reid
- Cystic Fibrosis Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John F Pohl
- Pediatric Gastroenterology, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Tatiana K Yuzyuk
- Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA
- ARUP Institute for Clinical & Experimental Pathology, Salt Lake City, Utah, USA
| | - Laura M Padula
- Pediatric Specialty, University Health, San Antonio, Texas, USA
| | - Kay Vavrina
- Pediatric Specialty, University Health, San Antonio, Texas, USA
| | - Kimberly Altman
- Gunnar Esiason Adult Cystic Fibrosis and Lung Center, Columbia University Medical Center, New York, New York, USA
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