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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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Eiamkulbutr S, Tubjareon C, Sanpavat A, Phewplung T, Srisan N, Sintusek P. Diseases of bile duct in children. World J Gastroenterol 2024; 30:1043-1072. [PMID: 38577180 PMCID: PMC10989494 DOI: 10.3748/wjg.v30.i9.1043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/26/2023] [Accepted: 02/04/2024] [Indexed: 03/06/2024] Open
Abstract
Several diseases originate from bile duct pathology. Despite studies on these diseases, certain etiologies of some of them still cannot be concluded. The most common disease of the bile duct in newborns is biliary atresia, whose prognosis varies according to the age of surgical correction. Other diseases such as Alagille syndrome, inspissated bile duct syndrome, and choledochal cysts are also time-sensitive because they can cause severe liver damage due to obstruction. The majority of these diseases present with cholestatic jaundice in the newborn or infant period, which is quite difficult to differentiate regarding clinical acumen and initial investigations. Intraoperative cholangiography is potentially necessary to make an accurate diagnosis, and further treatment will be performed synchronously or planned as findings suggest. This article provides a concise review of bile duct diseases, with interesting cases.
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Affiliation(s)
- Sutha Eiamkulbutr
- Department of Pediatrics, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Chomchanat Tubjareon
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Anapat Sanpavat
- Department of Pathology, Chulalongkorn University, Bangkok 10330, Thailand
| | - Teerasak Phewplung
- Department of Radiology, Chulalongkorn University, Bangkok 10330, Thailand
| | - Nimmita Srisan
- Department of Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Palittiya Sintusek
- Center of Excellence in Thai Pediatric Gastroenterology, Hepatology and Immunology, Division of Gastroenterology, Department of Pediatrics, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok 10330, Thailand
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Jeyaraj R, Maher ER, Kelly D. Paediatric research sets new standards for therapy in paediatric and adult cholestasis. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:75-84. [PMID: 38006895 DOI: 10.1016/s2352-4642(23)00259-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 11/27/2023]
Abstract
Children with Alagille syndrome and progressive familial intrahepatic cholestasis (PFIC) experience debilitating pruritus, for which there have been few effective treatment options. In the past 2 years, the ileal bile acid transporter (IBAT) inhibitors maralixibat and odevixibat have been approved for the management of cholestatic pruritus in these individuals, representing an important step forward in improving their quality of life. Emerging data suggest these drugs might also improve event-free survival, therefore potentially altering the typical disease course currently seen in these disorders. This Review will discuss how genetic advances have clarified the molecular basis of cholestatic disorders, facilitating the development of new therapeutic options that have only been evaluated in children. We focus specifically on the newly licensed IBAT inhibitors for patients with Alagille syndrome and PFIC and explore the next steps for these drugs in relation to other paediatric and adult cholestatic disorders, recognising that they have the potential to benefit a wider group of patients with gastrointestinal and liver disease.
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Affiliation(s)
- Rebecca Jeyaraj
- University College London Great Ormond Street Institute of Child Health, London, UK
| | - Eamonn R Maher
- Department of Medical Genetics, University of Cambridge, Cambridge, UK
| | - Deirdre Kelly
- The Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, UK; University of Birmingham, Birmingham, UK.
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Cheng K, Rosenthal P. Diagnosis and management of Alagille and progressive familial intrahepatic cholestasis. Hepatol Commun 2023; 7:e0314. [PMID: 38055640 PMCID: PMC10984671 DOI: 10.1097/hc9.0000000000000314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/12/2023] [Indexed: 12/08/2023] Open
Abstract
Alagille syndrome and progressive familial intrahepatic cholestasis are conditions that can affect multiple organs. Advancements in molecular testing have aided in the diagnosis of both. The impairment of normal bile flow and secretion leads to the various hepatic manifestations of these diseases. Medical management of Alagille syndrome and progressive familial intrahepatic cholestasis remains mostly targeted on supportive care focusing on quality of life, cholestasis, and fat-soluble vitamin deficiency. The most difficult therapeutic issue is typically related to pruritus, which can be managed by various medications such as ursodeoxycholic acid, rifampin, cholestyramine, and antihistamines. Surgical operations were previously used to disrupt enterohepatic recirculation, but recent medical advancements in the use of ileal bile acid transport inhibitors have shown great efficacy for the treatment of pruritus in both Alagille syndrome and progressive familial intrahepatic cholestasis.
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Affiliation(s)
- Katherine Cheng
- Department of Pediatrics Gastroenterology, Hepatology and Nutrition, University of California San Francisco, San Francisco, California, USA
| | - Philip Rosenthal
- Department of Pediatrics Gastroenterology, Hepatology and Nutrition, University of California San Francisco, San Francisco, California, USA
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
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Sokol RJ, Gonzales EM, Kamath BM, Baker A, Vig P, Mogul DB, Garner W, Hansen BE, Jacquemin E, Thompson RJ. Predictors of 6-year event-free survival in Alagille syndrome patients treated with maralixibat, an ileal bile acid transporter inhibitor. Hepatology 2023; 78:1698-1710. [PMID: 37278241 PMCID: PMC10653287 DOI: 10.1097/hep.0000000000000502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 05/14/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND AND AIMS Refractory pruritus and other complications of cholestasis are indications for liver transplantation (LT) in patients with Alagille syndrome (ALGS). We evaluated predictors of event-free survival and transplant-free survival in patients with ALGS treated with maralixibat (MRX), an ileal bile acid transporter inhibitor. APPROACH AND RESULTS We assessed patients with ALGS from 3 clinical trials of MRX with up to 6 years of follow-up. Event-free survival was defined as the absence of LT, surgical biliary diversion, hepatic decompensation, or death; transplant-free survival was the absence of LT or death. Forty-three potential predictors were evaluated, including age, pruritus (ItchRO[Obs] 0-4 scale), biochemistries, platelets, and serum bile acids. Harrell's concordance statistic assessed goodness-of-fit, and then, Cox proportional hazard models confirmed the statistical significance of the predictors identified. A further analysis was performed to identify cutoffs using a grid search. Seventy-six individuals met the criteria of receiving MRX for ≥48 weeks with laboratory values available at week 48 (W48). The median duration of MRX was 4.7 years (IQR: 1.6-5.8); 16 had events (10 LT, 3 decompensation, 2 death, and 1 surgical biliary diversion). The 6-year event-free survival improved with a clinically meaningful >1-point ItchRO(Obs) reduction from baseline to W48 (88% vs. 57%; p = 0.005), W48 bilirubin < 6.5 mg/dL (90% vs. 43%; p < 0.0001), and W48 serum bile acid < 200 µmol/L (85% vs. 49%; p = 0.001). These parameters were also predictive of 6-year transplant-free survival. CONCLUSIONS Improvement in pruritus by 48 weeks, and lower W48 bilirubin and serum bile acid levels were associated with fewer events. These data may help identify potential markers of disease progression for ALGS patients treated with MRX.
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Affiliation(s)
- Ronald J. Sokol
- Section of Pediatric Gastroenterology, Hepatology and Nutrition and the Digestive Health Institute, Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Emmanuel M. Gonzales
- Department of Pediatric Hepatology and Liver Transplantation, National reference center for biliary atresia and genetic cholestasis (AVB-CG), FSMR FILFOIE, ERN RARE-LIVER, AP-HP, Université Paris-Saclay, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- Department of Pediatric Hepatology and Liver Transplantation, Inserm UMR_S 1193, Université Paris-Saclay, FHU Hepatinov, Orsay, France
| | - Binita M. Kamath
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Alastair Baker
- Pediatric Liver Department, Pediatric Liver Centre, King’s College Hospital, London, UK
| | - Pamela Vig
- Department of Scientific and Medical Affairs, Mirum Pharmaceuticals Inc., Foster City, California, USA
| | - Douglas B. Mogul
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Will Garner
- Department of Scientific and Medical Affairs, Mirum Pharmaceuticals Inc., Foster City, California, USA
| | | | - Emmanuel Jacquemin
- Department of Pediatric Hepatology and Liver Transplantation, National reference center for biliary atresia and genetic cholestasis (AVB-CG), FSMR FILFOIE, ERN RARE-LIVER, AP-HP, Université Paris-Saclay, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- Department of Pediatric Hepatology and Liver Transplantation, Inserm UMR_S 1193, Université Paris-Saclay, FHU Hepatinov, Orsay, France
| | - Richard J. Thompson
- Department of Inflammation Biology, Institute of Liver Studies, King’s College London, London, UK
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Sweigart AJ, Moore A, Kendsersky R, Shah AA, Zook J. Evaluation of the Use of Naltrexone for Cholestatic Pruritus. J Pediatr Pharmacol Ther 2023; 28:524-529. [PMID: 38130341 PMCID: PMC10731951 DOI: 10.5863/1551-6776-28.6.524] [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: 09/05/2022] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Pruritus is a common symptom of liver disease, managed with various medications including opioid antagonists like naltrexone. Current literature surrounding the safety and efficacy of naltrexone for cholestatic pruritus is limited. Our objective was to describe naltrexone prescribing practices for cholestatic pruritus. METHODS We conducted a single-center, retrospective review of inpatients who received naltrexone for cholestatic pruritus. We gathered information on naltrexone dosing, frequency, dose adjustments, duration, elevations in liver function tests (LFTs), and use of additional antipruritic agents. RESULTS Thirty-nine patients and 122 dosing regimens were included for analysis. Most patients were male (56.4%) with a median age of 6.32 years (range, 0.63-18.89). The median weight-based doses of naltrexone were 1.45 mg/kg/dose (IQR, 0.84-2.81) and 1.86 mg/kg/day (IQR, 0.97-3.37). The median flat doses were 25 mg/dose (IQR, 12.25-50) and 50 mg/day (IQR, 25-50). The median number of additional antipruritic agents used before and after naltrexone initiation was 3 (IQR, 2-4) and 4 (IQR, 3-5), respectively (p < 0.001). The most common elevated LFTs were total bilirubin and alanine aminotransferase (ALT), occurring in 15% of patients. CONCLUSIONS Naltrexone dosing ranged between 1 and 2 mg/kg/dose once or twice daily, with larger weight-based doses prescribed in younger and lower-weight patients. Naltrexone was commonly added as a fourth-line agent and did not lead to discontinuation of other antipruritic therapies. Larger, prospective, controlled studies are needed to assess the safety and efficacy of naltrexone for cholestatic pruritus.
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Affiliation(s)
- Andrew J. Sweigart
- Department of Pharmacy (AJS, JZ, AM, RK), Children’s Hospital of Philadelphia, Division of Gastroenterology, Hepatology and Nutrition (AAS), Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Astrela Moore
- Department of Pharmacy (AJS, JZ, AM, RK), Children’s Hospital of Philadelphia, Division of Gastroenterology, Hepatology and Nutrition (AAS), Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rebecca Kendsersky
- Department of Pharmacy (AJS, JZ, AM, RK), Children’s Hospital of Philadelphia, Division of Gastroenterology, Hepatology and Nutrition (AAS), Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amit A. Shah
- Department of Pharmacy (AJS, JZ, AM, RK), Children’s Hospital of Philadelphia, Division of Gastroenterology, Hepatology and Nutrition (AAS), Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jessica Zook
- Department of Pharmacy (AJS, JZ, AM, RK), Children’s Hospital of Philadelphia, Division of Gastroenterology, Hepatology and Nutrition (AAS), Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Halma J, Lin HC. Alagille syndrome: understanding the genotype-phenotype relationship and its potential therapeutic impact. Expert Rev Gastroenterol Hepatol 2023; 17:883-892. [PMID: 37668532 DOI: 10.1080/17474124.2023.2255518] [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: 04/24/2023] [Accepted: 09/01/2023] [Indexed: 09/06/2023]
Abstract
INTRODUCTION Alagille syndrome (ALGS) is an autosomal dominant, multisystem genetic disorder with wide phenotypic variability caused by mutations in the Notch signaling pathway, specifically from mutations in either the Jagged1 (JAG1) or NOTCH2 gene. The range of clinical features in ALGS can involve various organ systems including the liver, heart, eyes, skeleton, kidney, and vasculature. Despite the genetic mutations being well-defined, there is variable expressivity and individuals with the same mutation may have different clinical phenotypes. AREAS COVERED While no clear genotype-phenotype correlation has been identified in ALGS, this review will summarize what is currently known about the genotype-phenotype relationship and how this relationship influences the treatment of the multisystemic disorder. This review includes discussion of numerous studies which have focused on describing the genotype-phenotype relationship of different organ systems in ALGS as well as relevant basic science and population studies of ALGS. A thorough literature search was completed via the PubMed and National Library of Medicine GeneReviews databases including dates from 1969, when ALGS was first identified, to February 2023. EXPERT OPINION The genetics of ALGS are well defined; however, ongoing investigation to identify genotype-phenotype relationships as well as genetic modifiers as potential therapeutic targets is needed. Clinicians and patients alike would benefit from identification of a correlation to aid in diagnostic evaluation and management.
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Affiliation(s)
- Jennifer Halma
- Division of Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Henry C Lin
- Division of Pediatric Gastroenterology, Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
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Ileal Bile Acid Transporter Blockers for Cholestatic Liver Disease in Pediatric Patients with Alagille Syndrome: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11247526. [PMID: 36556142 PMCID: PMC9784790 DOI: 10.3390/jcm11247526] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Alagille syndrome (ALGS) is a rare, debilitating inheritable disease that is associated with refractory pruritus due to chronic cholestasis. The following systemic review and meta-analysis presents the latest evidence for ileal bile acid transport (IBAT) blockers in AGLS patients in order to improve their efficacy. This study adhered to PRISMA 2020 Statement guidelines. A systematic search of PubMed/MEDLINE, Web of Science, Scopus, and the Cochrane library was conducted from inception until 23 October 2022. A combination of the following keywords was used: Alagille syndrome, therapeutics, treatment, therapy. Meta-analytical outcomes included effect directions of end-line changes in serum bile acids (sBAs), Itch Scale scores (ItchRO), Multidimensional Fatigue Scale scores, pediatric quality of life (QL), alanine aminotransferase (ALT), and total bilirubin. A total of 94 patients across four trials were enrolled and received maralixibat, odevixibat, or a placebo. There was a significant reduction in ItchRO scores by 1.8 points, as well as in sBAs by 75.8 μmol/L. Both the Multidimensional Fatigue Scale and Pediatric QL scale were also improved by 11.4 and 8.3 points, respectively. However, ALT levels were raised by 40 U/L. The efficacy of IBAT inhibitors across current trials was noted. Future trials may focus on the optimization of dosing regimens, considering gastrointestinal side effects and drug-induced ALT elevation in AGLS patients.
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Roberts AJ, Wales PW, Beath SV, Evans HM, Hind J, Mercer D, Wong T, Yap J, Belza C, Avitzur Y. An international multicenter validation study of the Toronto listing criteria for pediatric intestinal transplantation. Am J Transplant 2022; 22:2608-2615. [PMID: 35833730 DOI: 10.1111/ajt.17150] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/21/2022] [Accepted: 07/10/2022] [Indexed: 01/25/2023]
Abstract
Deciding which patients would benefit from intestinal transplantation (IT) remains an ethical/clinical dilemma. New criteria* were proposed in 2015: ≥2 intensive care unit (ICU) admissions, loss of ≥3 central venous catheter (CVC) sites, and persistently elevated conjugated bilirubin (CB ≥ 75 μmol/L) despite 6 weeks of lipid modification strategies. We performed a retrospective, international, multicenter validation study of 443 children (61% male, median gestational age 34 weeks [IQR 29-37]), diagnosed with IF between 2010 and 2015. Primary outcome measure was death or IT. Sensitivity, specificity, NPV, PPV, and probability of death/transplant (OR, 95% confidence intervals) were calculated for each criterion. Median age at IF diagnosis was 0.1 years (IQR 0.03-0.14) with median follow-up of 3.8 years (IQR 2.3-5.3). Forty of 443 (9%) patients died, 53 of 443 (12%) were transplanted; 11 died posttransplant. The validated criteria had a high predictive value of death/IT; ≥2 ICU admissions (p < .0001, OR 10.2, 95% CI 4.0-25.6), persistent CB ≥ 75 μmol/L (p < .0001, OR 8.2, 95% CI 4.8-13.9). and loss of ≥3 CVC sites (p = .0003, OR 5.7, 95% CI 2.2-14.7). This large, multicenter, international study in a contemporary cohort confirms the validity of the Toronto criteria. These validated criteria should guide listing decisions in pediatric IT.
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Affiliation(s)
- Amin J Roberts
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,New Zealand National Intestinal Failure and Rehabilitation Service (NZ-NIFRS), Starship Child Health, Auckland, New Zealand
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sue V Beath
- The Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Helen M Evans
- New Zealand National Intestinal Failure and Rehabilitation Service (NZ-NIFRS), Starship Child Health, Auckland, New Zealand
| | - Jonathan Hind
- Paediatric Liver, GI & Nutrition Centre, King's College Hospital, London, UK
| | - David Mercer
- Division of Transplantation, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Theodoric Wong
- Department of Gastroenterology and Nutrition, Nutritional Support and Intestinal Failure Team, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Jason Yap
- Division of Pediatric Gastroenterology, University of Alberta, Edmonton, Canada.,Department of Paediatric Gastroenterology and Nutrition, The Royal Children's Hospital, Melbourne, Australia
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Canada
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Putnam EM, Hong RA, Park JM, Li Y, Leis A, Malviya S. Intravenous ondansetron reduced nausea but not pruritus following intrathecal morphine in children: Interim results of a randomized, double-blinded, placebo-control trial. Paediatr Anaesth 2022; 32:1151-1158. [PMID: 35778960 PMCID: PMC9540995 DOI: 10.1111/pan.14517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 06/20/2022] [Accepted: 06/25/2022] [Indexed: 12/01/2022]
Abstract
STUDY OBJECTIVE This study's purpose was to determine if ondansetron can prevent pruritus after administration of intrathecal morphine in children, as has been demonstrated in adults. DESIGN A double-blinded, randomized placebo-controlled trial. SETTING Operating room and first 24 h postoperative inpatient stay at an academic children's hospital. PATIENTS Forty-six children aged 3-17 years, who received 4-5 mcg/kg intrathecal morphine for urological or orthopedic procedures were included. INTERVENTIONS Children were randomized to receive intravenous ondansetron (treatment) or saline placebo (placebo), prior to intrathecal morphine administration, and q6H for 24 h thereafter. Intraoperative anti-emetics and postoperative rescue treatments for pruritus and nausea were standardized. MEASUREMENTS Patients were interviewed q6H for scored pruritus, nausea, and pain, using standardized scales. MAIN RESULTS The trial was terminated for futility after interim analysis. Forty-six children were recruited and 45 completed data collection. No significant difference was found between both groups for incidence of pruritus (requiring treatment) [relative risk (RR) 0.9, 95% CI: 0.7, 1.2], during the first postoperative 24 h. Notably, the incidence of pruritus was 84% overall, much higher than rates in previously published studies. Intravenous ondansetron significantly reduced the incidence of nausea, compared with the placebo group [RR 0.5, 95% CI: 0.3, 0.9]. CONCLUSIONS This study found no evidence for intravenous ondansetron as an effective preventative for pruritus following intrathecal morphine in children. However, this RCT did find that the rate of pruritus following intrathecal morphine administration may be significantly higher than previously thought. Nausea and vomiting (a secondary outcome) were reduced significantly in the treatment group. The negative findings of this study reinforce the potential dangers of extrapolating the drug effects seen in adults onto pediatric patients.
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Affiliation(s)
- Elizabeth M. Putnam
- Department of AnesthesiologyUniversity of Michigan Health SystemAnn ArborMIUSA
| | - Rebecca A. Hong
- Department of AnesthesiologyUniversity of Michigan Health SystemAnn ArborMIUSA
| | - John M. Park
- Department of UrologyUniversity of Michigan Health SystemAnn ArborMIUSA
| | - Ying Li
- Depatment of Orthopaedic SurgeryUniversity of Michigan Health SystemAnn ArborMIUSA
| | - Aleda Leis
- Department of EpidemiologyUniversity of Michigan Health SystemAnn ArborMIUSA
| | - Shobha Malviya
- Department of AnesthesiologyUniversity of Michigan Health SystemAnn ArborMIUSA
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Ayoub MD, Kamath BM. Alagille Syndrome: Current Understanding of Pathogenesis, and Challenges in Diagnosis and Management. Clin Liver Dis 2022; 26:355-370. [PMID: 35868679 DOI: 10.1016/j.cld.2022.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Alagille syndrome (ALGS) is a complex heterogenous disease with a wide array of clinical manifestations in association with cholestatic liver disease. Major clinical and genetic advancements have taken place since its first description in 1969. However, clinicians continue to face considerable challenges in the management of ALGS, particularly in the absence of targeted molecular therapies. In this article, we provide an overview of the broad ALGS phenotype, current approaches to diagnosis and with particular focus on key clinical challenges encountered in the management of these patients.
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Affiliation(s)
- Mohammed D Ayoub
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Department of Pediatrics, Rabigh Branch, King Abdulaziz University, PO Box 80205, Jeddah 21589, Saudi Arabia
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
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12
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Nakajima H, Tsuma Y, Fukuhara S, Kodo K. A case of infantile Alagille syndrome with severe dyslipidemia: a new insight into lipid metabolism and therapeutics. J Endocr Soc 2022; 6:bvac005. [PMID: 35155971 PMCID: PMC8826833 DOI: 10.1210/jendso/bvac005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Indexed: 11/30/2022] Open
Abstract
Alagille syndrome (AGS) is an autosomal dominant genetic disorder characterized by congenital heart disease, hepatic cholestasis, dyslipidemia, and characteristic facies since infancy. Cholestatic hypercholesterolemia in patients diagnosed with AGS is occasionally refractory and resistant to conventional treatments. We report the case of a 4-month-old boy diagnosed with AGS and refractory dyslipidemia due to cholestatic liver disease. He had repeated episodes of cyanosis due to pulmonary artery atresia since birth and underwent a Blalock-Taussig shunt procedure at age 3 months. At age 4 months, cholestatic hyperbilirubinemia deteriorated to a serum total bilirubin level of 19.9 mg/dL. At age 12 months, a laboratory test revealed severe dyslipidemia (serum total cholesterol, 1796 mg/dL; serum triglycerides [TGs], 635 mg/dL), and the presence of xanthomas. A pathogenic variant of the JAG1 gene (c.1326G > A, p.Trp442X) was detected through genetic testing. Oral ursodeoxycholate normalized hyperbilirubinemia with a subtle improvement in dyslipidemia. Combination therapy with pravastatin and fenofibrate did not successfully improve dyslipidemia. At age 20 months, altering pravastatin to atorvastatin was effective in normalizing serum cholesterol and TGs with no adverse events. Combination therapy with atorvastatin and fenofibrate was successful in improving refractory dyslipidemia in a child with AGS. Atorvastatin is a well-known strong statin that can lower serum cholesterol, and fenofibrate can lower serum TG levels. We propose that atorvastatin be taken into consideration for the treatment of persistent hyperlipidemia in patients diagnosed with AGS, because atorvastatin upregulates bile acid synthesis and lipoprotein scavenging, and inhibits intrinsic cholesterol production.
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Affiliation(s)
- Hisakazu Nakajima
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Pediatrics, Midorigaoaka Hospital, Takatsuki, Osaka, Japan
| | - Yusuke Tsuma
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shota Fukuhara
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuki Kodo
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Gwaltney C, Bean S, Venerus M, Karlsson L, Warholic N, Kjems L, Horn P. Development of the Patient- and Observer-Reported PRUCISION Instruments to Assess Pruritus and Sleep Disturbance in Pediatric Patients with Cholestatic Liver Diseases. Adv Ther 2022; 39:5126-5143. [PMID: 36066744 PMCID: PMC9525401 DOI: 10.1007/s12325-022-02261-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 07/06/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Understanding how patients experience their disease is a vital step in optimal disease management, and patient- and observer-reported outcome (PRO and ObsRO, respectively) measures can add important details to clinical information that is obtained as novel treatments are developed. Instruments that measure meaningful symptoms and impacts from the perspective of pediatric patients with cholestatic liver disease or their caregivers are needed. This study aimed to identify salient concepts in pediatric cholestatic liver disease, develop novel PRO and ObsRO instruments, and establish the instruments' content validity. METHODS Relevant signs, symptoms, and impacts of cholestatic liver disease were identified through a literature review, interviews with expert clinicians, and concept elicitation interviews with children and caregivers of children who had progressive familial intrahepatic cholestasis (PFIC), Alagille syndrome, biliary atresia, or primary sclerosing cholangitis. Additional cognitive debriefing interviews with patients and caregivers were performed to ensure that participants could understand the instructions, questions, and response scales of the PRO and ObsRO instruments, with modifications made as necessary to improve comprehension and/or usability. RESULTS A total of 36 interviews with patients and caregivers were conducted. Pruritus and sleep disturbance (e.g., difficulty falling or staying asleep due to itch) were identified as the most problematic symptom and significant impact, respectively, of the pediatric cholestatic liver diseases assessed. The ObsRO and PRO instruments, called PRUCISION, focus on these key disease features in the morning and evening. Several modifications were made to the draft instruments following cognitive interviews. The final PRUCISION PRO and ObsRO measures are designed as an electronic diary to be completed twice daily. The response scales include pictorial, verbal, and numeric scales. CONCLUSION Novel PRO and ObsRO PRUCISION instruments were created that evaluate the patient experience of cholestatic pruritus in children with PFIC and other cholestatic liver diseases. The content validity of the PRUCISION instruments is established.
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Affiliation(s)
- Chad Gwaltney
- Gwaltney Consulting, 1 Bucks Trail, Westerly, RI 02891 USA
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14
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Meinel K, Szabo D, Dezsofi A, Pohl S, Strini T, Greimel T, Aguiriano-Moser V, Haidl H, Wagner M, Schlagenhauf A, Jahnel J. The Covert Surge: Murine Bile Acid Levels Are Associated With Pruritus in Pediatric Autoimmune Sclerosing Cholangitis. Front Pediatr 2022; 10:903360. [PMID: 35633951 PMCID: PMC9130722 DOI: 10.3389/fped.2022.903360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The exact etiology of pruritus in chronic cholestasis is unknown. Pruritus intensity does not correlate with common biochemical indices and there is a lack of biomarkers guiding diagnosis and treatment. We explored profiles of bile acids (BA) and muricholic acids (MCA) as well as autotaxin (ATX) antigen levels as potential circulating biomarkers of pruritus in pediatric patients. METHODS In 27 pediatric cholestatic patients [autoimmune sclerosing cholangitis (ASC) n = 20 (with pruritus n = 6, without pruritus n = 14); progressive familial intrahepatic cholestasis (PFIC) n = 7 (with pruritus n = 5, without pruritus n = 2)] and 23 age-matched controls pruritus was assessed by a visual analog scale of pruritus (PVAS). We obtained profiles of serum human BA including MCA using a mass-spectrometry assay and ATX antigen levels with a commercial ELISA. RESULTS PFIC and ASC patients exhibited significantly higher BA-, and MCA levels, than healthy controls, but only PFIC patients showed elevated ATX antigen levels higher [median: 1,650 ng/ml, interquartile rang (IQR): 776.9-3,742] compared to controls (median: 315.9 ng/ml, IQR: 251.1-417.2; PFIC p = 0.0003). ASC patients with pruritus showed only a minor increase in total BA (tBA) levels (median: 76.5 μmol/L, IQR: 54.7-205), but strikingly higher T-conjugated BA (median: 16.4 μmol/L, IQR: 8.9-41.4) and total MCA (tMCA) (median: 1.15 μmol/L, IQR: 0.77-2.44) levels compared to ASC patients without pruritus (tBA median: 24.3 μmol/L, IQR: 16.2-80.8; p < 0.0408; T-conjugated BA median: 1.3 μmol/L, IQR: 0.8-4.9; p = 0.0023; tMCA median: 0.30 μmol/L, IQR: 0.13-0.64, p = 0.0033). BA/MCA profiles distinctly differed depending on presence/absence of pruritus. Different from PFIC patients, ATX antigen levels were not significantly elevated in ASC patients with (median: 665.8 ng/ml, IQR: 357.8-1,203) and without pruritus (median: 391.0 ng/ml, IQR: 283.2-485.6). In ASC patients, tBA, tMCA, and ATX antigen levels did not correlate with pruritus severity. CONCLUSION Despite the same underlying disease, pediatric ASC patients with pruritus exhibit significantly altered BA profiles and MCA levels compared to ASC patients without pruritus. ATX antigen levels seem to have little diagnostic or prognostic meaning in ASC patients. An increased ATX activity alone seems not to be causal for pruritus genesis in ASC patients. CLINICAL TRIAL REGISTRATION [www.drks.de], identifier [DRKS00026913].
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Affiliation(s)
- Katharina Meinel
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Doloresz Szabo
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Antal Dezsofi
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Sina Pohl
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Tanja Strini
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Theresa Greimel
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Victor Aguiriano-Moser
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Harald Haidl
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Martin Wagner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Axel Schlagenhauf
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Jörg Jahnel
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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15
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Gonzales E, Hardikar W, Stormon M, Baker A, Hierro L, Gliwicz D, Lacaille F, Lachaux A, Sturm E, Setchell KDR, Kennedy C, Dorenbaum A, Steinmetz J, Desai NK, Wardle AJ, Garner W, Vig P, Jaecklin T, Sokal EM, Jacquemin E. Efficacy and safety of maralixibat treatment in patients with Alagille syndrome and cholestatic pruritus (ICONIC): a randomised phase 2 study. Lancet 2021; 398:1581-1592. [PMID: 34755627 DOI: 10.1016/s0140-6736(21)01256-3] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 05/05/2021] [Accepted: 05/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Alagille syndrome is a rare genetic disease that often presents with severe cholestasis and pruritus. There are no approved drugs for management. Maralixibat, an apical, sodium-dependent, bile acid transport inhibitor, prevents enterohepatic bile acid recirculation. We evaluated the safety and efficacy of maralixibat for children with cholestasis in Alagille syndrome. METHODS ICONIC was a placebo-controlled, randomised withdrawal period (RWD), phase 2b study with open-label extension in children (aged 1-18 years) with Alagille syndrome (NCT02160782). Eligible participants had more than three times the normal serum bile acid (sBA) levels and intractable pruritus. After 18 weeks of maralixibat 380 μg/kg once per day, participants were randomly assigned (1:1) to continue maralixibat or receive placebo for 4 weeks. Subsequently, all participants received open-label maralixibat until week 48. During the long-term extension (204 weeks reported), doses were increased up to 380 μg/kg twice per day. The primary endpoint was the mean sBA change during the RWD in participants with at least 50% sBA reduction by week 18. Cholestastic pruritus was assessed using observer-rated, patient-rated, and clinician-rated 0-4 scales. The safety population was defined as all participants who had received at least one dose of maralixibat. This trial was registered with ClinicalTrials.gov, NCT02160782, and is closed to recruitment. FINDINGS Between Oct 28, 2014, and Aug 14, 2015, 31 participants (mean age 5·4 years [SD 4·25]) were enrolled and 28 analysed at week 48. Of the 29 participants who entered the randomised drug withdrawal period, ten (34%) were female and 19 (66%) were male. In the RWD, participants switched to placebo had significant increases in sBA (94 μmol/L, 95% CI 23 to 164) and pruritus (1·7 points, 95% CI 1·2 to 2·2), whereas participants who continued maralixibat maintained treatment effect. This study met the primary endpoint (least square mean difference -117 μmol/L, 95% CI -232 to -2). From baseline to week 48, sBA (-96 μmol/L, -162 to -31) and pruritus (-1·6 pts, -2·1 to -1·1) improved. In participants who continued to week 204 (n=15) all improvements were maintained. Maralixibat was generally safe and well tolerated throughout. The most frequent adverse events were gastrointestinal related. Most adverse events were self-limiting in nature and mild-to-moderate in severity. INTERPRETATION In children with Alagille syndrome, maralixibat is, to our knowledge, the first agent to show durable and clinically meaningful improvements in cholestasis. Maralixibat might represent a new treatment paradigm for chronic cholestasis in Alagille syndrome. FUNDING Mirum Pharmaceuticals.
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Affiliation(s)
- Emmanuel Gonzales
- Hépatologie et Transplantation Hépatique Pédiatriques, Centre de référence de l'atrésie des voies biliaires et des cholestases génétiques, FSMR FILFOIE, ERN RARE LIVER, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Hépatinov, Inserm U 1193, Le Kremlin-Bicêtre, France.
| | - Winita Hardikar
- Department of Gastroenterology, The Royal Children's Hospital Melbourne, Parkville, VIC, Australia
| | - Michael Stormon
- Department of Gastroenterology, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Alastair Baker
- Department of Child Health, The Paediatric Liver Centre, King's College Hospital, London, UK
| | - Loreto Hierro
- Servicio de Hepatologìa y Trasplante Pediátrico, Hospital Universitario La Paz, Madrid, Spain
| | - Dorota Gliwicz
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, Children's Memorial Health Institute, Warsaw, Poland
| | - Florence Lacaille
- Gastroenterology-Hepatology-Nutrition Unit, Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Alain Lachaux
- Service de Gastroentérologie, Hépatologie et Nutrition Pédiatriques, Centre de référence de la maladie de Wilson et autres maladies rares liées au cuivre, Centre de référence de l'atrésie des voies biliaires et cholestases génétiques, Hôpital Femme-Mère-Enfant, Lyon, France
| | - Ekkehard Sturm
- Paediatric Gastroenterology/Hepatology, University Hospital for Children and Adolescents, Tübingen, Germany
| | - Kenneth D R Setchell
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Alejandro Dorenbaum
- Pediatrics - Immunology and Allergy, Stanford Medical School, Stanford University, Palo Alto, CA, USA
| | | | | | | | | | - Pamela Vig
- Mirum Pharmaceuticals, Foster City, CA, USA
| | | | - Etienne M Sokal
- UCLouvain, Cliniques Universitaires Saint Luc, Service de Gastroentérologie Hépatologie Pédiatrique, Brussels, Belgium
| | - Emmanuel Jacquemin
- Hépatologie et Transplantation Hépatique Pédiatriques, Centre de référence de l'atrésie des voies biliaires et des cholestases génétiques, FSMR FILFOIE, ERN RARE LIVER, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Hépatinov, Inserm U 1193, Le Kremlin-Bicêtre, France
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16
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Lykavieris P, Bernard O, Jacquemin E. Ursodeoxycholic acid therapy throughout pregnancy in women affected with chronic cholestasis of childhood: No evidence for teratogenicity. Clin Res Hepatol Gastroenterol 2021; 45:101472. [PMID: 32565202 DOI: 10.1016/j.clinre.2020.05.020] [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: 04/15/2020] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Panayotis Lykavieris
- Pediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Biliary Atresia and Genetic Cholestasis, FILFOIE, ERN RARE LIVER, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, University Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, France
| | - Olivier Bernard
- Pediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Biliary Atresia and Genetic Cholestasis, FILFOIE, ERN RARE LIVER, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, University Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, France
| | - Emmanuel Jacquemin
- Pediatric Hepatology and Liver Transplantation Unit, National Reference Centre for Biliary Atresia and Genetic Cholestasis, FILFOIE, ERN RARE LIVER, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, University Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, France; INSERM U1193, Hepatinov, University Paris-Saclay, Orsay, France.
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17
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Murray-Brown FL. Naltrexone for cholestatic itch: a systematic review. BMJ Support Palliat Care 2021; 11:217-225. [PMID: 33692114 DOI: 10.1136/bmjspcare-2020-002801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/18/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Cholestatic itch is caused by intrahepatic liver diseases, such as primary biliary cirrhosis and extrahepatic obstruction of the biliary tree, often caused by tumours. The pathophysiology of cholestatic itch is complex and no single treatment has proved definitive. Naltrexone is an opioid receptor antagonist, which reduces central opioidergic tone, believed to be raised in patients with cholestatic pruritus. AIM To review and assess the efficacy of oral naltrexone for the treatment of cholestatic itch. METHODS Search of electronic databases, grey literature, clinical trials registries and handsearching for studies including naltrexone for cholestatic itch. Full papers were obtained if relevant and studies graded. RESULTS Thirteen papers were included in the analysis, including three randomised controlled trials, one controlled clinical trial, one open-label pilot study, seven case reports and one retrospective notes review. All studies found naltrexone to be effective in relieving pruritus. In all five studies performing statistical analysis, naltrexone significantly reduced pruritus compared with baseline. 37% of patients reported side effects, notably opioid withdrawal-type reactions and recurrence of previous pain, from all pathologies. CONCLUSIONS Oral naltrexone therapy helps relieve cholestatic itch and although it should be used with caution in patients using exogenous opioids for analgesia, it should be considered when treating refractory pruritus in patients with end-stage liver disease.
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18
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Neonatale Cholestase. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-020-01042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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19
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Ayoub MD, Kamath BM. Alagille Syndrome: Diagnostic Challenges and Advances in Management. Diagnostics (Basel) 2020; 10:E907. [PMID: 33172025 PMCID: PMC7694636 DOI: 10.3390/diagnostics10110907] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/21/2022] Open
Abstract
Alagille syndrome (ALGS) is a multisystem disease characterized by cholestasis and bile duct paucity on liver biopsy in addition to variable involvement of the heart, eyes, skeleton, face, kidneys, and vasculature. The identification of JAG1 and NOTCH2 as disease-causing genes has deepened our understanding of the molecular mechanisms underlying ALGS. However, the variable expressivity of the clinical phenotype and the lack of genotype-phenotype relationships creates significant diagnostic and therapeutic challenges. In this review, we provide a comprehensive overview of the clinical characteristics and management of ALGS, and the molecular basis of ALGS pathobiology. We further describe unique diagnostic considerations that pose challenges to clinicians and outline therapeutic concepts and treatment targets that may be available in the near future.
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Affiliation(s)
- Mohammed D. Ayoub
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada;
- Department of Pediatrics, Faculty of Medicine, Rabigh Branch, King Abdulaziz University, P.O. Box 80205, Jeddah 21589, Saudi Arabia
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada;
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20
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Kelly C, Nayagam JS, Vogli S, Samyn M, Joshi D. Paediatric cholestatic liver disorders for the adult gastroenterologist: a practical guide. Frontline Gastroenterol 2020; 12:404-413. [PMID: 35401959 PMCID: PMC8989003 DOI: 10.1136/flgastro-2020-101554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/16/2020] [Accepted: 06/20/2020] [Indexed: 02/04/2023] Open
Abstract
With improvements in the outcomes for cholestatic liver diseases that present in childhood, increasing numbers of patients will require ongoing care as adults. The recent advances in management options coupled with the fact that each adult physician will have a limited number of patients with these conditions means there is a need for those in adult services to develop expertise in these conditions that were historically the domain of paediatrics. This review provides an overview of the most common paediatric cholestatic liver diseases and outlines the clinical manifestations and potential complications, and identifies key management issues unique to each condition for effective ongoing care of these patients.
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Affiliation(s)
- Claire Kelly
- Institute of Liver Studies, King's College Hospital, London, UK
| | | | - Stamatina Vogli
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Marianne Samyn
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
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21
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Kamath BM, Stein P, Houwen RHJ, Verkade HJ. Potential of ileal bile acid transporter inhibition as a therapeutic target in Alagille syndrome and progressive familial intrahepatic cholestasis. Liver Int 2020; 40:1812-1822. [PMID: 32492754 PMCID: PMC7496162 DOI: 10.1111/liv.14553] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/15/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022]
Abstract
Alagille syndrome (ALGS) and progressive familial intrahepatic cholestasis (PFIC) are rare, inherited cholestatic liver disorders that manifest in infants and children and are associated with impaired bile flow (ie cholestasis), pruritus and potentially fatal liver disease. There are no effective or approved pharmacologic treatments for these diseases (standard medical treatments are supportive only), and new, noninvasive options would be valuable. Typically, bile acids undergo biliary secretion and intestinal reabsorption (ie enterohepatic circulation). However, in these diseases, disrupted secretion of bile acids leads to their accumulation in the liver, which is thought to underlie pruritus and liver-damaging inflammation. One approach to reducing pathologic bile acid accumulation in the body is surgical biliary diversion, which interrupts the enterohepatic circulation (eg by diverting bile acids to an external stoma). These procedures can normalize serum bile acids, reduce pruritus and liver injury and improve quality of life. A novel, nonsurgical approach to interrupting the enterohepatic circulation is inhibition of the ileal bile acid transporter (IBAT), a key molecule in the enterohepatic circulation that reabsorbs bile acids from the intestine. IBAT inhibition has been shown to reduce serum bile acids and pruritus in trials of paediatric cholestatic liver diseases. This review explores the rationale of inhibition of the IBAT as a therapeutic target, describes IBAT inhibitors in development and summarizes the current data on interrupting the enterohepatic circulation as treatment for cholestatic liver diseases including ALGS and PFIC.
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Affiliation(s)
- Binita M. Kamath
- The Hospital for Sick ChildrenTorontoONCanada
- University of TorontoTorontoONCanada
| | | | | | - Henkjan J. Verkade
- University of GroningenBeatrix Children’s Hospital/University Medical Center GroningenGroningenThe Netherlands
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22
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Junge N, Dingemann J, Petersen C, Manns MP, Richter N, Klempnauer J, Baumann U, Schneider A. [Biliary atresia and congenital cholestatic syndromes : Characteristics before, after and during transition]. Internist (Berl) 2018; 59:1146-1156. [PMID: 30264190 DOI: 10.1007/s00108-018-0506-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND A growing number of patients with biliary atresia and congenital cholestatic syndromes are reaching adulthood. These patients often have a number of typical medical features, including specific characteristics of liver transplantation medicine. OBJECTIVE What are the special features in the care of adults suffering from liver diseases with manifestation in childhood and adolescence, both before and after liver transplantation (LTX). How does the progression of individual diseases differ depending on age at manifestation? What are specific aspects following pediatric LTX? PATIENTS AND METHODS Evaluation and discussion of existing guidelines and recommendations of the individual disciplines and professional societies as well as the current literature. Joint discussion of the recommendations between disciplines (gastroenterology, pediatric gastroenterology, surgery). Inclusion of center-specific experiences with transition from existing transition outpatient departments and training. RESULTS The recommendations are presented specifically for each disease. Special features in individual diseases after LTX are also discussed. Diagnosis-independent general treatment concepts for cholestasis and chronic liver disease are presented. CONCLUSION Patients with biliary atresia and congenital cholestatic syndromes have a life-long chronic liver disease with and without LTX and require specific medical care. The patients benefit from the pooling of expertise in the individual disciplines.
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Affiliation(s)
- N Junge
- Klinik für Pädiatrische Nieren‑, Leber- und Stoffwechselerkrankungen, Schwerpunkt Pädiatrische Gastroenterologie und Hepatologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - J Dingemann
- Klinik für Kinderchirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - C Petersen
- Klinik für Kinderchirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - M P Manns
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - N Richter
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - J Klempnauer
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - U Baumann
- Klinik für Pädiatrische Nieren‑, Leber- und Stoffwechselerkrankungen, Schwerpunkt Pädiatrische Gastroenterologie und Hepatologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - A Schneider
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover, Deutschland
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Abstract
BACKGROUND AND AIM Alagille syndrome (ALGS) is an inherited multisystem disorder typically manifesting as cholestasis, and potentially leading to end-stage liver disease and death. The aim of the study was to perform the first systematic review of the epidemiology, natural history, and burden of ALGS with a focus on the liver component. METHODS Electronic databases and proceedings from key congresses were searched in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 guidelines. This analysis included publications reporting epidemiology, natural history, economic burden or health-related quality of life (HRQoL) outcomes in patients with ALGS. RESULTS Of 525 screened publications, 20 met the inclusion criteria. Liver-related features included cholestasis (87%-100% of patients), jaundice (66%-85%), and cirrhosis (44%-95%). Between 15% and 47% of patients underwent liver transplantation and 4% to 14% received partial biliary diversion. Pruritus affected the majority of patients (59%-88%, of whom up to 45% had severe pruritus) and manifested during the first 10 years of life. Children with ALGS had significantly impaired HRQoL compared with healthy controls and those with other diseases. Itching was the symptom that most affected children with ALGS. No study assessed the economic burden of ALGS. CONCLUSIONS Our findings consolidate information on the clinical course of ALGS, and highlight gaps in knowledge, most notably the absence of any research on the economic consequences of the disease. Further research is needed to establish the incidence of genetically confirmed ALGS. Disease-specific tools are also needed to improve the measurement of symptoms, such as itching, and better understand the impact of ALGS on HRQoL.
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Abstract
The liver and kidneys are often similarly affected by a single disease. This is the case in metabolic, immunological, toxic, and infectious diseases, and in the different congenital malformation syndromes. Also, an enzymatic defect in an otherwise healthy liver or the consequences of advanced liver disease by itself can cause kidney disease as a secondary phenomenon. In this review, we describe numerous pathogenic mechanisms leading to dysfunction or malformations of the liver and kidneys in children. We encourage multidisciplinary management for optimal care. A combined liver-kidney transplantation is sometimes needed.
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Li J, Dawson PA. Animal models to study bile acid metabolism. Biochim Biophys Acta Mol Basis Dis 2018; 1865:895-911. [PMID: 29782919 DOI: 10.1016/j.bbadis.2018.05.011] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/11/2018] [Accepted: 05/14/2018] [Indexed: 12/19/2022]
Abstract
The use of animal models, particularly genetically modified mice, continues to play a critical role in studying the relationship between bile acid metabolism and human liver disease. Over the past 20 years, these studies have been instrumental in elucidating the major pathways responsible for bile acid biosynthesis and enterohepatic cycling, and the molecular mechanisms regulating those pathways. This work also revealed bile acid differences between species, particularly in the composition, physicochemical properties, and signaling potential of the bile acid pool. These species differences may limit the ability to translate findings regarding bile acid-related disease processes from mice to humans. In this review, we focus primarily on mouse models and also briefly discuss dietary or surgical models commonly used to study the basic mechanisms underlying bile acid metabolism. Important phenotypic species differences in bile acid metabolism between mice and humans are highlighted.
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Affiliation(s)
- Jianing Li
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Emory University, Atlanta, GA 30322, United States
| | - Paul A Dawson
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Emory University, Atlanta, GA 30322, United States.
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Thébaut A, Debray D, Gonzales E. An update on the physiopathology and therapeutic management of cholestatic pruritus in children. Clin Res Hepatol Gastroenterol 2018; 42:103-109. [PMID: 29031874 DOI: 10.1016/j.clinre.2017.08.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/18/2017] [Accepted: 08/25/2017] [Indexed: 02/06/2023]
Abstract
Pruritus is a disabling symptom accompanying chronic cholestasis. In extreme cases, the refractory nature of pruritus can result in a need for invasive therapies including liver transplantation. The pathogenesis of pruritus in cholestatic disease is poorly understood. It may involve a specific neural pathway (similar to that associated with pain) regulated by several pruritogenic substances such as bile acids, opioids, serotonin, and the more recently identified lysophosphatidic acid. While the therapeutic management of cholestatic pruritus is well established in adults, there is no consensus in children, in light of the difficulty of conducting controlled clinical studies. The currently recommended strategy to manage cholestatic pruritus in children is based on several lines of specific therapies that should be associated with skin hydration and with non-specific treatment of cholestasis including ursodeoxycholic acid. Pruritus should be assessed as objectively as possible between each line of therapy. Rifampicin, a potent CYP3A4 inducer, is the first-line treatment of cholestatic pruritus. Second-line therapies require evaluation of the child in an expert center and are discussed on a case-by-case basis depending on the underlying disease and the experience of the center. These include inhibitors of serotonin reuptake (sertraline), opioid antagonists (naloxone), or ASBT inhibitors. Invasive therapies such as biliary diversion or liver transplantation can also be proposed in the most severe cases. The aim of the current update is to review the physiopathologic mechanisms implicated in cholestatic pruritus and to propose potential therapeutic strategies in children.
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Affiliation(s)
- A Thébaut
- Hépatologie et transplantation hépatique pédiatrique, hôpital Bicêtre, université Paris-Sud-11, Assistance Publique-Hôpitaux de Paris, 78, rue du Général-Leclerc, 94270 Le-Kremlin-Bicêtre, France; Inserm UMR-S-1174, Université-Paris-Sud-11, Orsay, France
| | - D Debray
- Hépatologie pédiatrique, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France; Inserm UMR-S-938, centre de recherche Saint-Antoine, Paris cedex 12, France
| | - E Gonzales
- Hépatologie et transplantation hépatique pédiatrique, hôpital Bicêtre, université Paris-Sud-11, Assistance Publique-Hôpitaux de Paris, 78, rue du Général-Leclerc, 94270 Le-Kremlin-Bicêtre, France; Inserm UMR-S-1174, Université-Paris-Sud-11, Orsay, France.
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Chkheidze R, Joseph R, Burner J, Matevosyan K. Plasma exchange for the management of refractory pruritus of cholestasis: A report of three cases and review of literature. J Clin Apher 2017; 33:412-418. [DOI: 10.1002/jca.21573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 07/17/2017] [Accepted: 07/21/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Rati Chkheidze
- Department of Pathology; University of Texas Southwestern Medical Center; Dallas TX 75390
| | - Ranjit Joseph
- Department of Pathology; University of Texas Southwestern Medical Center; Dallas TX 75390
| | - James Burner
- Department of Pathology; University of Texas Southwestern Medical Center; Dallas TX 75390
| | - Karen Matevosyan
- Department of Pathology; University of Texas Southwestern Medical Center; Dallas TX 75390
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Thébaut A, Debray D, Gonzales E. Physiopathologie et prise en charge thérapeutique du prurit cholestatique de l’enfant. Arch Pediatr 2017; 24:682-688. [DOI: 10.1016/j.arcped.2017.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/10/2017] [Accepted: 04/24/2017] [Indexed: 01/12/2023]
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Ben Ameur S, Chabchoub I, Telmoudi J, Belfitouri Y, Rebah O, Lacaille F, Aloulou H, Mehrzi A, Hachicha M. Management of cholestatic pruritus in children with Alagille syndrome: Case report and literature review. Arch Pediatr 2017; 23:1247-1250. [PMID: 28492167 DOI: 10.1016/j.arcped.2016.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 05/18/2016] [Accepted: 09/23/2016] [Indexed: 11/17/2022]
Abstract
Alagille syndrome causes intractable pruritus and disfiguring xanthomas because of retained bile acids and cholesterol. Drug therapy in addition to surgical intervention may be effective in many patients in reducing serum bile acids, cholesterol levels, pruritus, and skin xanthomas. In this report, we describe a child with Alagille syndrome who presented with severe pruritus and xanthomas as a consequence of severe hypercholesterolemia and discuss the treatment modalities.
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Affiliation(s)
- S Ben Ameur
- Pediatric department, Hedi Chaker Hospital, El ain street km 0,5, 3029 Sfax, Tunisia; Faculty of medicine, university of Sfax, Tunisia.
| | - I Chabchoub
- Pediatric department, Hedi Chaker Hospital, El ain street km 0,5, 3029 Sfax, Tunisia
| | - J Telmoudi
- Pediatric department, Hedi Chaker Hospital, El ain street km 0,5, 3029 Sfax, Tunisia
| | - Y Belfitouri
- Pediatric department, Hedi Chaker Hospital, El ain street km 0,5, 3029 Sfax, Tunisia
| | - O Rebah
- Pediatric department, La Marsa Hospital, Tunis, Tunisia
| | - F Lacaille
- Hepatogastroenterology-nutrition unit, Hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - H Aloulou
- Pediatric department, Hedi Chaker Hospital, El ain street km 0,5, 3029 Sfax, Tunisia
| | - A Mehrzi
- Pediatric department, La Marsa Hospital, Tunis, Tunisia
| | - M Hachicha
- Pediatric department, Hedi Chaker Hospital, El ain street km 0,5, 3029 Sfax, Tunisia
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Abstract
OBJECTIVES Pruritus is a severe symptom accompanying chronic cholestasis. It can be debilitating and difficult to control. In children, first-line treatments are ursodeoxycholic acid and rifampicin. Refractory pruritus may require invasive therapies including liver transplantation. Clinical trials based on small samples of adult patients suggest that serotonin reuptake inhibitors can improve pruritus in cholestatic or uremic disease. We performed a prospective, multicenter study to assess efficiency and safety of the serotonin reuptake inhibitor sertraline in treating children with refractory cholestatic pruritus. METHODS Twenty children experiencing refractory cholestatic pruritus related to Alagille syndrome or progressive familial intrahepatic cholestasis were included from 4 centers between 2007 and 2014, and treated with sertraline at a starting dose of 1 mg · kg · day and thereafter individually adapted up to 4 mg · kg · day. Before and after 3 months with therapy, pruritus was assessed using a visual itching scale graded on 10 points, a skin scratch marks score and a sleeping impairment score. RESULTS Sertraline was prescribed at a median daily dose of 2.2 mg · kg · day. After 3 months, pruritus improved in 14 out of 20 treated patients, and the median itching score decreased significantly from 8/10 (5-10) to 5/10 (2-10). Likewise, skin scratch marks and sleep quality improved in 9 of these 14 patients. Nonsevere adverse events were reported in 6 children, leading to treatment discontinuation in 3. CONCLUSION Our data suggest that sertraline may constitute a useful drug in the management of refractory cholestatic pruritus in children.
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Jagadisan B, Srivastava A. Child with Jaundice and Pruritus: How to Evaluate? Indian J Pediatr 2016; 83:1311-1320. [PMID: 26932879 DOI: 10.1007/s12098-016-2058-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 02/01/2016] [Indexed: 12/01/2022]
Abstract
Jaundice with pruritus is a manifestation of cholestasis. The defective biliary drainage causes accumulation of substances that are usually excreted in bile, which in turn causes pruritus. The exact nature of the pruritogen is under evaluation. However, lysophosphatidic acid is the current favourite. The causes of cholestasis can be broadly classified as intra or extrahepatic, with intrahepatic disorders being more often associated with pruritus. Cholestatic phase of acute viral hepatitis, progressive familial intrahepatic cholestasis, syndromic and non-syndromic paucity of intralobular bile ductules, drug induced cholestasis and sclerosing cholangitis (SC) are the common causes in children. An algorithmic approach facilitates early etiological diagnosis by careful clinical evaluation combined with investigations including gamma glutamyl transpeptidase, radiological imaging (ultrasonography, magnetic resonance cholangiopancreatography), liver biopsy and genetic analysis. Management is largely supportive and includes nutritional rehabilitation with supplement of fat soluble vitamins and calcium, stepwise therapy of pruritus with drugs (ursodeoxycholic acid, rifampicin, bile acid sequestrants and/or opioid antagonists) and biliary diversion surgery. Complications of advanced liver disease and portal hypertension need to be addressed. Liver transplantation is required in children with refractory pruritus affecting the quality of life or those with end stage liver disease. Relief of biliary obstruction by endoscopy or surgery and treatment of diseases associated with SC like histiocytosis may be rewarding. Long-term follow-up for development of complications of liver disease and hepatocellular/ cholangiocarcinoma is essential. Thus, an early diagnosis and stepwise treatment with an understanding of the pathogenesis of pruritus in cholestatic disorders may decrease morbidity and mortality.
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Affiliation(s)
- Barath Jagadisan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India.
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Khalaf R, Phen C, Karjoo S, Wilsey M. Cholestasis beyond the Neonatal and Infancy Periods. Pediatr Gastroenterol Hepatol Nutr 2016; 19:1-11. [PMID: 27066444 PMCID: PMC4821977 DOI: 10.5223/pghn.2016.19.1.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 02/14/2016] [Accepted: 02/16/2016] [Indexed: 02/07/2023] Open
Abstract
Cholestasis results from impairment in the excretion of bile, which may be due to mechanical obstruction of bile flow or impairment of excretion of bile components into the bile canaliculus. When present, cholestasis warrants prompt diagnosis and treatment. The differential diagnosis of cholestasis beyond the neonatal period is broad and includes congenital and acquired etiologies. It is imperative that the clinician differentiates between intrahepatic and extrahepatic origin of cholestasis. Treatment may be supportive or curative and depends on the etiology. Recent literature shows that optimal nutritional and medical support also plays an integral role in the management of pediatric patients with chronic cholestasis. This review will provide a broad overview of the pathophysiology, diagnostic approach, and management of cholestasis beyond the neonatal and infancy periods.
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Affiliation(s)
- Racha Khalaf
- Department of Medical Education, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Claudia Phen
- Department of Medical Education, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Sara Karjoo
- Department of Gastroenterology and Nutrition, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Michael Wilsey
- Department of Gastroenterology and Nutrition, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States
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Ramachandran P, Shanmugam NP, Sinani SA, Shanmugam V, Srinivas S, Sathiyasekaran M, Tamilvanan V, Rela M. Outcome of partial internal biliary diversion for intractable pruritus in children with cholestatic liver disease. Pediatr Surg Int 2014; 30:1045-9. [PMID: 25064227 DOI: 10.1007/s00383-014-3559-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2014] [Indexed: 12/14/2022]
Abstract
PURPOSE Children with cholestatic disorders have undergone liver transplantation for intractable pruritus unresponsive to medical therapy even in the absence of liver failure. Biliary diversion procedures interrupt the entero-hepatic circulation of bile acids allowing them to be excreted in the feces thereby lowering the total bile acid pool. We evaluated the outcome of partial internal biliary diversion (PIBD) in children with intractable pruritus from inherited cholestatic disorders. METHODS The records of children who underwent PIBD over a 4-year period were reviewed for etiology of liver disease, demographic data, preoperative and postoperative biochemical profile and improvement of pruritus. Standard statistical methods were used for analysis. RESULTS Of the 12 children, 10 had progressive familial intrahepatic cholestasis (PFIC) and 2 had Alagille syndrome (AS). PIBD was done using an isolated jejunal loop as a conduit from gall bladder to mid ascending colon. Median period of follow up was 30 months. Pruritus resolved in nine children with significant reduction of serum bile acids (P < 0.02). CONCLUSION To our knowledge, this is the largest reported series of children with PIBD. PIBD is a safe, well-tolerated and effective alternative to liver transplant in children with PFIC and AS who have intractable pruritus in the absence of synthetic liver failure.
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Affiliation(s)
- P Ramachandran
- Kanchi Kamakoti Childs Trust Hospital and Childs Trust Medical Research Foundation, Chennai, India,
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Annunziato RA, Parbhakar M, Helcer J, Kapoor K, Henkel K, Arnon R. Strategies for Measuring Quality of Life among Pediatric Solid-Organ Transplant Recipients. Prog Transplant 2014; 24:247-56. [DOI: 10.7182/pit2014171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Quality of life (QoL) has become a mainstay in the outcome assessment of pediatric solid-organ transplant recipients. Yet, how QoL is operationalized and measured varies drastically. It may be very difficult for clinicians and researchers to determine which methods of QoL assessment best meet the needs of their patients or study. The purpose of this literature review is to describe and evaluate the current status of QoL measurement in studies of pediatric solid-organ transplant recipients. Data Sources Searches of PubMed and PsycINFO from January 1985 to February 2012. Study Selection English peer-reviewed publications that described a method for measuring QoL whether it was a standardized questionnaire, qualitative approach, or another way of operationalizing the construct. Data Extraction QoL measurement strategies were extracted from 43 studies that met inclusion criteria. Data Synthesis Each article was reviewed and summarized by 2 study team members. Conclusions Many different strategies were used for measurement, and some were not consistent with established conceptualizations of QoL. Overall recommendations for best practices are offered. Detailed information about specific measures is included, and measures that seem to capture the construct well are recommended. Additionally, our review highlighted the importance of using a “battery approach,” including child and parent report as well as considering other variables, such as patient's age, when selecting a QoL measurement strategy.
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Affiliation(s)
- Rachel A. Annunziato
- Fordham University, Bronx, New York (RAA, MP, JH, KH), Icahn School of Medicine at Mount Sinai, New York (KK, RA)
| | - Meera Parbhakar
- Fordham University, Bronx, New York (RAA, MP, JH, KH), Icahn School of Medicine at Mount Sinai, New York (KK, RA)
| | - Jacqueline Helcer
- Fordham University, Bronx, New York (RAA, MP, JH, KH), Icahn School of Medicine at Mount Sinai, New York (KK, RA)
| | - Kathryn Kapoor
- Fordham University, Bronx, New York (RAA, MP, JH, KH), Icahn School of Medicine at Mount Sinai, New York (KK, RA)
| | - Kristen Henkel
- Fordham University, Bronx, New York (RAA, MP, JH, KH), Icahn School of Medicine at Mount Sinai, New York (KK, RA)
| | - Ronen Arnon
- Fordham University, Bronx, New York (RAA, MP, JH, KH), Icahn School of Medicine at Mount Sinai, New York (KK, RA)
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Dawson PA, Karpen SJ. Bile acids reach out to the spinal cord: new insights to the pathogenesis of itch and analgesia in cholestatic liver disease. Hepatology 2014; 59:1638-41. [PMID: 24532150 PMCID: PMC3966955 DOI: 10.1002/hep.26786] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 09/22/2013] [Indexed: 01/20/2023]
Abstract
Patients with cholestatic disease exhibit pruritus and analgesia, but the mechanisms underlying these symptoms are unknown. We report that bile acids, which are elevated in the circulation and tissues during cholestasis, cause itch and analgesia by activating the GPCR TGR5. TGR5 was detected in peptidergic neurons of mouse dorsal root ganglia and spinal cord that transmit itch and pain, and in dermal macrophages that contain opioids. Bile acids and a TGR5-selective agonist induced hyperexcitability of dorsal root ganglia neurons and stimulated the release of the itch and analgesia transmitters gastrin-releasing peptide and leucine-enkephalin. Intradermal injection of bile acids and a TGR5-selective agonist stimulated scratching behavior by gastrin-releasing peptide- and opioid-dependent mechanisms in mice. Scratching was attenuated in Tgr5-KO mice but exacerbated in Tgr5-Tg mice (overexpressing mouse TGR5), which exhibited spontaneous pruritus. Intraplantar and intrathecal injection of bile acids caused analgesia to mechanical stimulation of the paw by an opioid-dependent mechanism. Both peripheral and central mechanisms of analgesia were absent from Tgr5-KO mice. Thus, bile acids activate TGR5 on sensory nerves, stimulating the release of neuropeptides in the spinal cord that transmit itch and analgesia. These mechanisms could contribute to pruritus and painless jaundice that occur during cholestatic liver diseases.
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Affiliation(s)
- Paul A. Dawson
- Department of Internal Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston Salem, NC 27157
| | - Saul J. Karpen
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia,Correspondence to: Paul A. Dawson, Ph.D., Department of Internal Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157; Tel: 336-716-4633; Fax: 336-716-6279; ; or Saul J. Karpen, M.D., Ph.D., Division Chief, Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Children’s Healthcare of Atlanta, Emory Children’s Center, 2015 Uppergate Drive, NE, Suite 208E, Atlanta, Georgia 30322.
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Scratching the itch of cholestatic pruritus: room for improvement in therapeutic strategies. J Pediatr Gastroenterol Nutr 2013; 57:133. [PMID: 23619029 DOI: 10.1097/mpg.0b013e318297e281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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