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Simmonds NJ, Southern KW, De Wachter E, De Boeck K, Bodewes F, Mainz JG, Middleton PG, Schwarz C, Vloeberghs V, Wilschanski M, Bourrat E, Chalmers JD, Ooi CY, Debray D, Downey DG, Eschenhagen P, Girodon E, Hickman G, Koitschev A, Nazareth D, Nick JA, Peckham D, VanDevanter D, Raynal C, Scheers I, Waller MD, Sermet-Gaudelus I, Castellani C. ECFS standards of care on CFTR-related disorders: Identification and care of the disorders. J Cyst Fibros 2024; 23:590-602. [PMID: 38508949 DOI: 10.1016/j.jcf.2024.03.008] [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: 11/21/2023] [Revised: 02/06/2024] [Accepted: 03/08/2024] [Indexed: 03/22/2024]
Abstract
This is the third paper in the series providing updated information and recommendations for people with cystic fibrosis transmembrane conductance regulator (CFTR)-related disorder (CFTR-RD). This paper covers the individual disorders, including the established conditions - congenital absence of the vas deferens (CAVD), diffuse bronchiectasis and chronic or acute recurrent pancreatitis - and also other conditions which might be considered a CFTR-RD, including allergic bronchopulmonary aspergillosis, chronic rhinosinusitis, primary sclerosing cholangitis and aquagenic wrinkling. The CFTR functional and genetic evidence in support of the condition being a CFTR-RD are discussed and guidance for reaching the diagnosis, including alternative conditions to consider and management recommendations, is provided. Gaps in our knowledge, particularly of the emerging conditions, and future areas of research, including the role of CFTR modulators, are highlighted.
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Affiliation(s)
- N J Simmonds
- Adult Cystic Fibrosis Centre, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, UK.
| | - K W Southern
- Department of Women's and Children's Health, University of Liverpool, University of Liverpool, Alder Hey Children's Hospital, Liverpool, UK
| | - E De Wachter
- Cystic Fibrosis Center, Pediatric Pulmonology department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - K De Boeck
- Department of Pediatrics, University of Leuven, Leuven, Belgium
| | - F Bodewes
- Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Groningen Medical Center, Groningen, the Netherlands
| | - J G Mainz
- Cystic Fibrosis Center, Brandenburg Medical School (MHB), University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - P G Middleton
- Cystic Fibrosis and Bronchiectasis Service, Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, News South Wales, Australia
| | - C Schwarz
- HMU-Health and Medical University Potsdam, CF Center Westbrandenburg, Campus Potsdam, Germany
| | - V Vloeberghs
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - M Wilschanski
- CF Center, Department of Pediatrics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - E Bourrat
- APHP, Service de Dermatologie, CRMR MAGEC Nord St Louis, Hôpital-Saint Louis, Paris, France
| | - J D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - C Y Ooi
- a) School of Clinical Medicine, Discipline of Paediatrics and Child Health, Medicine & Health, University of New South Wales, Level 8, Centre for Child Health Research & Innovation Bright Alliance Building Cnr Avoca & High Streets, Randwick, Sydney, NSW, Australia, 2031; b) Sydney Children's Hospital, Gastroenterology Department, High Street, Randwick, Sydney, NSW, Australia, 2031
| | - D Debray
- Pediatric Hepatology unit, Centre de Référence Maladies Rares (CRMR) de l'atrésie des voies biliaires et cholestases génétiques (AVB-CG), National network for rare liver diseases (Filfoie), ERN rare liver, Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, Paris, France; Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - D G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | | - E Girodon
- Service de Médecine Génomique des Maladies de Système et d'Organe, APHP.Centre - Université de Paris Cité, Hôpital Cochin, Paris, France
| | - G Hickman
- APHP, Service de Dermatologie, CRMR MAGEC Nord St Louis, Hôpital-Saint Louis, Paris, France
| | - A Koitschev
- Klinikum Stuttgart, Pediatric Otorhinolaryngology, Stuttgart, Germany
| | - D Nazareth
- a) Adult CF Unit, Liverpool Heart and Chest Hospital NHS Foundation Trust, U.K; b) Clinical Infection, Microbiology and Immunology, University of Liverpool, UK
| | - J A Nick
- Department of Medicine, National Jewish Health, Denver, CO, 80206, USA, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - D Peckham
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - D VanDevanter
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - C Raynal
- Laboratory of molecular genetics, University Hospital of Montpellier and INSERM U1046 PHYMEDEXP, Montpellier, France
| | - I Scheers
- Department of Pediatrics, Pediatric Gastroenterology and Hepatology Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - M D Waller
- Adult Cystic Fibrosis and Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; Honorary Senior Lecturer, King's College London, London, United Kingdom
| | - I Sermet-Gaudelus
- INSERM U1151, Institut Necker Enfants Malades, Paris, France; Université de Paris, Paris, France; Centre de référence Maladies Rares, Mucoviscidose et maladies apparentées, Hôpital Necker Enfants malades, Paris, France
| | - C Castellani
- IRCCS Istituto Giannina Gaslini, Cystic Fibrosis Center, Genoa, Italy
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Zhang T, Liu Q, Li Z, Tang S, An Q, Fan D, Xiang Y, Wu X, Jin Z, Ding J, Hu Y, Du Q, Xu J, Xie R. The role of ion channels in immune-related diseases. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2023; 177:129-140. [PMID: 36417963 DOI: 10.1016/j.pbiomolbio.2022.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/26/2022] [Accepted: 11/10/2022] [Indexed: 11/21/2022]
Abstract
Ion channel is an integral membrane protein that allows the permeation of charge ions across hydrophobic phospholipid membranes, including plasma membranes and organelle membranes (such as mitochondria, endoplasmic reticulum and vacuoles), which are widely distributed in various cells and tissues, such as cardiomyocytes, smooth muscle cells, and nerve cells. Ion channels establish membrane potential by regulating ion concentration and membrane potential. Membrane potential plays an important role in cells. Studies have shown that ion channels play a role in a number of immune-related diseases caused by functional defects in ion channels on immune or non-immune cells in major human organs, usually affecting specific organs or multiple organs. The present review discusses the relationship between ion channels and immune diseases in major organs of the human body.
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Affiliation(s)
- Ting Zhang
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Qi Liu
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Zhuo Li
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Siqi Tang
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Qimin An
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Dongdong Fan
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yiwei Xiang
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Xianli Wu
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Zhe Jin
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jianhong Ding
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yanxia Hu
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Qian Du
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jingyu Xu
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China.
| | - Rui Xie
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi, China.
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Parisi GF, Mòllica F, Giallongo A, Papale M, Manti S, Leonardi S. Cystic fibrosis transmembrane conductance regulator (CFTR): beyond cystic fibrosis. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2022. [DOI: 10.1186/s43042-022-00308-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The cystic fibrosis transmembrane conductance regulator (CFTR) gene has been traditionally linked to cystic fibrosis (CF) inheritance in an autosomal recessive manner. Advances in molecular biology and genetics have expanded our understanding of the CFTR gene and its encoding products expressed in different tissues.
Aim
The study’s aim consists of reviewing the different pathological CF phenotypes using the existing literature. We know that alterations of the CFTR protein’s structure may result in different pathological phenotypes.
Methods
Open sources such as PubMed and Science Direct databases have been used for this review. We focused our selection on articles published within the last 15 years. Critical terms related to the CFTR protein have been used: “CFTR AND cancer,” “CFTR AND celiac disease,” “CFTR AND pancreatitis,” “children,” “adults,” “genotype,” “phenotype,” “correlation,” “mutation,” “CFTR,” “diseases,” “disorders,” and “no cystic fibrosis.”
Results
We analyzed 1,115 abstracts in total. Moreover, only 189 were suitable for the topic. We focused on the role of CFTR in cancer, gastrointestinal disorders, respiratory diseases, reproductive system, and systemic hypertension.
Conclusions
Mutations in CFTR gene are often associated with CF. In this review, we highlighted the broad spectrum of alterations reported for this gene, which may be involved in the pathogenesis of other diseases. The importance of these new insights in the role of CFTR relies on the possibility of considering this protein/gene as a novel therapeutic target for CF- and CFTR-related diseases.
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Arslan AB, Zamani AG, Pekcan S, Yıldırım MS. A Novel Pathogenic Variant of the CFTR Gene in a Patient with Cystic Fibrosis Phenotype-c.4096A > T. J Pediatr Genet 2020; 9:40-43. [PMID: 31976142 DOI: 10.1055/s-0039-1694964] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 07/11/2019] [Indexed: 10/26/2022]
Abstract
Cystic fibrosis is a chronic multisystemic disease originating from functional alterations in CFTR (cystic fibrosis transmembrane conductance regulator) protein. To date, more than 300 pathogenic variants have been described in the literature. However, the diagnosis of CF, which was thought to become easier after the CFTR gene was identified, became more complicated due to the enormous amount of variations. In this study, we present a patient whose clinical findings were consistent with cystic fibrosis (CF) and showed a homozygous missense change that is not previously reported in the CFTR gene as pathogenic. In the next-generation sequencing analysis, homozygous c.4096A > T single-nucleotide exchange (I1366F [p.Ile1366Phe], missense) was shown in both alleles of the patient' CFTR gene. According to our database analysis, this variant has not yet been previously reported (VarSome, ClinVar, MutationTaster, Ensembl, dbSNP, PubMed). We do consider the change as pathogenic since the patient's findings were compatible with CF and the data analysis was in favor of pathogenicity. The most recent consensus report published in 2017 emphasized the importance of CFTR gene analysis, and this study emphasizes the difficulties of associating CFTR gene variations with a clinical picture and constitutes a new data on the genotype-phenotype correlation of CFTR variants. Also, considering the frequency of CF (according to World Health Organization data, every 1 out of 2,000-3,000 infants is born with CF in European Union countries and every 1 out of 3,500 in the United States) as well as the increasing rate of molecular studies performed on CF patients worldwide, reporting novel variation has an additional value.
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Affiliation(s)
- Ahmet Burak Arslan
- Department of Medical Genetics, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Ayşe Gül Zamani
- Department of Medical Genetics, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Sevgi Pekcan
- Pediatric Pulmonology Division, Department of Pediatrics, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Mahmut Selman Yıldırım
- Department of Medical Genetics, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
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Werlin S, Scotet V, Uguen K, Audrezet MP, Cohen M, Yaakov Y, Safadi R, Ilan Y, Konikoff F, Galun E, Mizrahi M, Slae M, Sayag S, Cohen-Cymberknoh M, Wilschanski M, Ferec C. Primary sclerosing cholangitis is associated with abnormalities in CFTR. J Cyst Fibros 2018; 17:666-671. [PMID: 29807875 DOI: 10.1016/j.jcf.2018.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 04/13/2018] [Accepted: 04/22/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND The etiology of primary sclerosing cholangitis (PSC) is unknown. PSC and Cystic Fibrosis related liver disease have common features: chronic inflammation, biliary damage and similar cholangiographic findings. It is unknown whether or not PSC is related to cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction. We hypothesize that a sub-group of PSC patients may be a "single-organ" presentation of CF. METHODS Patients with PSC underwent nasal potential difference (NPD) measurement, sweat chloride measurement and complete CFTR sequencing by new generation sequencing. RESULTS 6/32 patients aged 46 ± 13 yrs. had CFTR causing mutations on one allele and 19 had CFTR polymorphisms; 6/23 tested had abnormal and 21 had intermediate sweat tests; 4/32 patients had abnormal NPD. One patient had chronic pancreatitis and was infertile. CONCLUSIONS 19% of PSC patients had features of CFTR related disorder, 19% carry CFTR mutations and 50% had CFTR polymorphisms. In some patients, PSC may be a single organ presentation of CF or a CFTR-related disorder.
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Affiliation(s)
- Steven Werlin
- Pediatric Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginie Scotet
- Laboratory of Molecular Genetics and Histocompatibility, University Hospital of Brest, Institut National de la Santé et de la Recherche Médicale, U1078 Brest, France
| | - Kevin Uguen
- Laboratory of Molecular Genetics and Histocompatibility, University Hospital of Brest, Institut National de la Santé et de la Recherche Médicale, U1078 Brest, France
| | - Marie-Pierre Audrezet
- Laboratory of Molecular Genetics and Histocompatibility, University Hospital of Brest, Institut National de la Santé et de la Recherche Médicale, U1078 Brest, France
| | - Michael Cohen
- Pediatric Gastroenterology Unit and Cystic Fibrosis Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yasmin Yaakov
- Pediatric Gastroenterology Unit and Cystic Fibrosis Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Rifaat Safadi
- Liver Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Yaron Ilan
- Liver Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Fred Konikoff
- Gastroenterology and Hepatology Department, Meir Medical Center, Kfar Saba, Israel
| | - Eitan Galun
- Goldyne Savad Institute of Gene Therapy, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Meir Mizrahi
- Liver Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Mordechai Slae
- Pediatric Gastroenterology Unit and Cystic Fibrosis Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Shirley Sayag
- Pediatric Gastroenterology Unit and Cystic Fibrosis Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Malena Cohen-Cymberknoh
- Pediatric Pulmonology Unit and Cystic Fibrosis Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michael Wilschanski
- Pediatric Gastroenterology Unit and Cystic Fibrosis Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - Claude Ferec
- Laboratory of Molecular Genetics and Histocompatibility, University Hospital of Brest, Institut National de la Santé et de la Recherche Médicale, U1078 Brest, France
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Staufer K, Halilbasic E, Trauner M, Kazemi-Shirazi L. Cystic fibrosis related liver disease--another black box in hepatology. Int J Mol Sci 2014; 15:13529-49. [PMID: 25093717 PMCID: PMC4159809 DOI: 10.3390/ijms150813529] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/10/2014] [Accepted: 07/16/2014] [Indexed: 02/07/2023] Open
Abstract
Due to improved medical care, life expectancy in patients with cystic fibrosis (CF) has veritably improved over the last decades. Importantly, cystic fibrosis related liver disease (CFLD) has become one of the leading causes of morbidity and mortality in CF patients. However, CFLD might be largely underdiagnosed and diagnostic criteria need to be refined. The underlying pathomechanisms are largely unknown, and treatment strategies with proven efficacy are lacking. This review focuses on current invasive and non-invasive diagnostic standards, the current knowledge on the pathophysiology of CFLD, treatment strategies, and possible future developments.
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Affiliation(s)
- Katharina Staufer
- Division of Transplantation, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
| | - Emina Halilbasic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
| | - Lili Kazemi-Shirazi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
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7
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Pollheimer MJ, Fickert P, Stieger B. Chronic cholestatic liver diseases: clues from histopathology for pathogenesis. Mol Aspects Med 2013; 37:35-56. [PMID: 24141039 DOI: 10.1016/j.mam.2013.10.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 10/04/2013] [Accepted: 10/07/2013] [Indexed: 02/06/2023]
Abstract
Chronic cholestatic liver diseases include fibrosing cholangiopathies such as primary biliary cirrhosis or primary sclerosing cholangitis. These and related cholangiopathies clearly display pathologies associated with (auto)immunologic processes. As the cholangiocyte's apical membrane is exposed to the toxic actions of the bile fluid, the interaction of bile with cholangiocytes and the biliary tree in general must be considered to completely understand the pathogenesis of cholangiopathies. While the molecular processes involved in the hepatocellular formation of bile are well understood in both normal and pathophysiologic conditions, those in the bile ducts of normal liver and in livers with cholangiopathies lag behind. This survey highlights key mechanisms known to date that are important for the formation of bile by hepatocytes and its modification by the biliary tree. It also delineates the clinical pathophysiologic findings for cholangiopathies and puts them in perspective with current experimental models to reveal the pathogenesis of cholangiopathies and develop novel therapeutic approaches.
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Affiliation(s)
- Marion J Pollheimer
- Division of Gastroenterology and Hepatology, Laboratory of Experimental and Molecular Hepatology, Department of Internal Medicine, Medical University of Graz, Austria; Institute of Pathology, Medical University of Graz, Austria
| | - Peter Fickert
- Division of Gastroenterology and Hepatology, Laboratory of Experimental and Molecular Hepatology, Department of Internal Medicine, Medical University of Graz, Austria; Institute of Pathology, Medical University of Graz, Austria.
| | - Bruno Stieger
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland.
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Imam MH, Talwalkar JA, Lindor KD. Secondary sclerosing cholangitis: pathogenesis, diagnosis, and management. Clin Liver Dis 2013; 17:269-77. [PMID: 23540502 DOI: 10.1016/j.cld.2012.11.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Secondary sclerosing cholangitis (SSC) is an aggressive and rare disease with intricate pathogenesis and multiple causes. Understanding the specific cause underlying each case of SSC is crucial in the clinical management of the disease. Radiologic imaging can help diagnose SSC and hence institute management in a timely manner. Management may encompass simple interventions, such as supportive therapy, antibiotics, and monitoring, or more serious measures, such as surgery, endoscopic intervention, or liver transplantation. Patients with AIDS cholangiopathy have limited therapeutic options and worsened survival. The disease should always be highly suspected in patients with primary sclerosing cholangitis with questionable diagnosis.
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Affiliation(s)
- Mohamad H Imam
- Cholestatic Liver Diseases Study Group, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Trivedi PJ, Chapman RW. PSC, AIH and overlap syndrome in inflammatory bowel disease. Clin Res Hepatol Gastroenterol 2012; 36:420-36. [PMID: 22306055 DOI: 10.1016/j.clinre.2011.10.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Revised: 10/08/2011] [Accepted: 10/14/2011] [Indexed: 02/07/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a progressive, cholestatic disorder characterised by chronic inflammation and stricture formation of the biliary tree. Symptoms include pruritus, fatigue and in advanced cases ascending cholangitis, cirrhosis and end-stage hepatic failure. Patients are at an increased risk of malignancy arising from the bile ducts, gallbladder, liver and colon. The majority (>80%) of Northern European patients with PSC also have inflammatory bowel disease (IBD), usually ulcerative colitis (UC). IBD commonly presents before the onset of PSC, although the opposite can occur and the onset of both conditions can be separated by many years. The colitis associated with PSC is characteristically mild although frequently involves the whole colon. Despite the majority of patients having relatively inactive colonic disease, paradoxically the risk of colorectal malignancy is substantially increased. Patients may also develop dominant, stenotic lesions of the biliary tree which may be difficult to differentiate from cholangiocarcinoma and the coexistence of IBD may influence the development of this complication. Ursodeoxycholic acid may offer a chemoprotective effect against colorectal malignancy and improve liver biochemical indices. Evidence of any beneficial effect on histological progression of hepatobiliary disease is less clear. High doses (∼25-30 mg/kg/d) may be harmful and should be avoided. Autoimmune hepatitis (AIH) is less common in patients with IBD than PSC, however, an association has been observed. A small subgroup may have an overlap syndrome between AIH and PSC and management should be individualised dependant on liver histology, serum immunoglobulin levels, autoantibodies, degree of biochemical cholestasis and cholangiography.
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Affiliation(s)
- P J Trivedi
- Centre for Liver Research and NIHR Biomedical Research Unit, University of Birmingham, Wolfson Drive, Edgbaston, Birmingham, B15 2TT United Kingdom.
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Abstract
Primary sclerosing cholangitis (PSC) is a chronic inflammatory liver disease characterized by the destruction of medium- to large-sized bile ducts and intense concentric fibrosis. Complications from PSC include bacterial cholangitis, cirrhosis, and cholangiocarcinoma and a therapy that might alter the natural history of the disease remains lacking. Our understanding of the pathogenesis of PSC also remains rudimentary but the strong association between PSC and inflammatory bowel disease suggest causal links between the diseases. The male predominance in PSC, lack of a defined, pathogenic auto-antigen, and the potential role of the innate immune system suggest that PSC may be due to dysregulation of immunity rather than a classic autoimmune disease. However, PSC shares several genetic susceptibility loci with other autoimmune diseases including the human leukocyte antigen DRB01*03 haplotype. The precise immune response of PSC is largely unknown but likely involves activation of the innate immune system by bacterial components delivered to the liver via the portal vein. Induction of adhesion molecules and chemokines leads to the recruitment of intestinal lymphocytes. Bile duct injury results from the sustained inflammation and production of inflammatory cytokines. Biliary strictures may cause further damage as a result of bile stasis and recurrent secondary bacterial cholangitis. Progress in our basic understanding of PSC is desperately needed in order to rationally design new therapeutic approaches to this disease.
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Affiliation(s)
- Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis Medical Center, Sacramento, USA.
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Parés A. [Primary sclerosing cholangitis: diagnosis, prognosis and treatment]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:41-52. [PMID: 20435377 DOI: 10.1016/j.gastrohep.2010.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 02/12/2010] [Indexed: 05/29/2023]
Abstract
Primary sclerosing cholangitis is a chronic cholestatic disease characterized by inflammation with fibrosis and obliteration of the intra- and extrahepatic bile ducts. This disease is usually associated with ulcerative colitis. The process of chronic cholestasis eventually leads to biliary cirrhosis. The prevalence of primary sclerosing cholangitis is low in southern Europe but is especially high in Scandinavian countries. The etiopathogenesis is unknown but immune disorders, potential toxic agents or intestinal infections, ischemic injury to the bile ducts, and possibly alterations in hepatobiliary transporters are known to play a role. The disease manifests at the age of approximately 40 years, mainly in men with clinical and laboratory features of cholestasis but may also be asymptomatic. There are specific forms in which the small intrahepatic bile ducts are involved, mainly affecting children, as well as overlap syndromes with autoimmune hepatitis. A form characterized by an increase in IgG4 has been described, which is usually associated with autoimmune pancreatitis. The key diagnostic procedure is endoscopic retrograde cholangiography, although magnetic resonance cholangiography is the first diagnostic procedure that should be used since it is equally informative and non-invasive. Liver biopsy is not essential for diagnosis. Primary sclerosing cholangitis is a progressive disease with a probability of transplant-free survival of 18 years in asymptomatic forms and of 8.5 years in symptomatic forms. Cholangiocarcinoma can result from the disease and confers a poor prognosis. There is no specific treatment although ursodeoxycholic acid improves the biochemical alterations of cholestasis. Liver transplantation is the last therapeutic resort with good results in terms of survival although the disease can recur in the transplanted liver.
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Affiliation(s)
- Albert Parés
- Unidad de Hepatología, Institut de Malalties Digestives, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Universidad de Barcelona, Barcelona, Spain.
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Karlsen TH, Schrumpf E, Boberg KM. Update on primary sclerosing cholangitis. Dig Liver Dis 2010; 42:390-400. [PMID: 20172772 DOI: 10.1016/j.dld.2010.01.011] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2009] [Accepted: 01/17/2010] [Indexed: 02/06/2023]
Abstract
Early studies in primary sclerosing cholangitis (PSC) were concerned with disease characterization, and were followed by epidemiological studies of PSC and clinical subsets of PSC as well as a large number of treatment trials. Recently, the molecular pathogenesis and the practical handling of the patients have received increasing attention. In the present review we aim to give an update on the pathogenesis of PSC and cholangiocarcinoma in PSC, as well as to discuss the current opinion on diagnosis and treatment of PSC in light of the recent European Association for the Study of the Liver and the American Association for the Study of Liver Diseases practice guidelines.
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Affiliation(s)
- Tom H Karlsen
- Norwegian PSC Research Center, Medical Department, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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14
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Abstract
PURPOSE OF REVIEW Many of the cholestatic diseases show similar clinical features, despite underlying differences in the genetic etiology. The present review aims to present recent insight into this etiological heterogeneity. RECENT FINDINGS Mutations in the genes causing progressive familial intrahepatic cholestasis are also involved in less severe phenotypes like benign recurrent intrahepatic cholestasis, gallstone disease, intrahepatic cholestasis of pregnancy and drug-induced cholestasis. This probably represents a continuum of severity of the mutations involved, but also complex patterns of inheritance ranging from monogenic autosomal recessive disorders to heterozygosity only conferring a moderate increase in disease risk, where additional genetic or environmental factors are needed to acquire a disease phenotype. Recent genome-wide association studies in the inflammatory cholestatic diseases primary biliary cirrhosis and primary sclerosing cholangitis have revealed susceptibility genes involved in autoimmunity and inflammatory bowel disease, whereas the genetic risk factors for the biliary preference of these diseases remain unknown. SUMMARY The complexity of the genetic contribution to cholestatic liver disease needs to be accounted for to fully understand the pathogenesis of these conditions.
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Stanca CM, Babar J, Singal V, Ozdenerol E, Odin JA. Pathogenic role of environmental toxins in immune-mediated liver diseases. J Immunotoxicol 2009; 5:59-68. [PMID: 18382859 DOI: 10.1080/15476910802019086] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Immune-mediated liver diseases contribute significantly to morbidity and mortality due to liver failure and the need for liver transplantation. The pathogenesis of the immune-mediated chronic liver diseases, primary sclerosing cholangitis, autoimmune hepatitis, and primary biliary cirrhosis, is poorly understood. Genetic susceptibility factors may play a role, but increasing attention is being given to the association between environmental factors and these diseases. The existence of such a relationship is supported by epidemiologic surveys, animal models, and geographic clustering analyses. Unearthing the cause of this association may provide insight into the pathogenesis of immune-mediated chronic liver diseases and autoimmunity.
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Affiliation(s)
- Carmen M Stanca
- Department of Medicine, The Mount Sinai School of Medicine, New York, New York 10029, USA
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16
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Henckaerts L, Jaspers M, Van Steenbergen W, Vliegen L, Fevery J, Nuytten H, Roskams T, Rutgeerts P, Cassiman JJ, Vermeire S, Cuppens H. Cystic fibrosis transmembrane conductance regulator gene polymorphisms in patients with primary sclerosing cholangitis. J Hepatol 2009; 50:150-7. [PMID: 18992954 DOI: 10.1016/j.jhep.2008.07.033] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 07/16/2008] [Accepted: 07/21/2008] [Indexed: 12/04/2022]
Abstract
BACKGROUND/AIMS Primary sclerosing cholangitis (PSC) is a progressive cholestatic disease commonly associated with inflammatory bowel disease (IBD) and characterized by fibrosing inflammatory destruction of bile ducts. The histological features in the liver of PSC patients are similar to those observed in cystic fibrosis (CF). Our aim was to study whether variants in the CFTR gene are associated with the occurrence and/or evolution of PSC. METHODS PSC patients (n=140) were genotyped for F508del, the TGmTn variants, and four additional polymorphic loci (1001+11 C>T, M470V, T854T and Q1463Q), and compared to 136 matched healthy controls. RESULTS The 1540G-allele, encoding V470, was less frequent in PSC (52%) than in controls (64%, p=0.003), and was associated with protection against PSC in individuals without IBD (OR 0.25, 95% CI 0.12-0.52, p=0.0002). Also TG11-T7 was less frequent in PSC (53%) than in controls (61%, p=0.04), this haplotype was associated with reduced risk for PSC (OR 0.34, 95% CI 0.17-0.70, p=0.003) in individuals without IBD. CONCLUSIONS In this cohort of PSC patients, several CFTR-variants affecting the functional properties of the CFTR protein seem to offer protection against the development of PSC, confirming our hypothesis that CFTR might be implicated in the pathogenesis of PSC.
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Affiliation(s)
- Liesbet Henckaerts
- Department of Gastroenterology, University Hospital Gasthuisberg, Catholic University of Leuven, Herestraat 49, B-3000 Leuven, Belgium.
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17
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Abstract
Autoinflammatory liver disease represents an important aspect of global hepatological practice. The three principal disease divisions recognized are autoimmune hepatitis, primary sclerosing cholangitis and primary biliary cirrhosis. Largely, but not exclusively, these diseases are considered to be autoimmune in origin. Increased recognition of outlier and overlap syndromes, changes in presentation and natural history, as well as the increased awareness of IgG4-associated sclerosing cholangitis, all highlight the limitations of the classic terminology. New insights continue to improve the care given to patients, and have arisen from carefully conducted clinical studies, therapeutic trials, as well as genetic and laboratory investigations. The challenges remain to treat patients before liver injury becomes permanent and to prevent the development of organ failure.
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Affiliation(s)
- Teru Kumagi
- Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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18
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The challenges in primary sclerosing cholangitis--aetiopathogenesis, autoimmunity, management and malignancy. J Hepatol 2008; 48 Suppl 1:S38-57. [PMID: 18304683 DOI: 10.1016/j.jhep.2008.01.020] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease, characterized by progressive inflammation and fibrosis of the bile ducts, resulting in biliary cirrhosis and is associated with a high risk of cholangiocarcinoma. The majority of patients are young, male and have coexisting inflammatory bowel disease. PSC is found with a prevalence of 10/100,000 in Northern European populations. The pathophysiology of PSC is a complex multistep process including immunological mechanisms, immunogenetic susceptibility and disorders of the biliary epithelia. The diagnosis is primarily based on endoscopic cholangiography although magnetic resonance imaging is increasingly used; biochemistry and immunoserology as well as histology play only a minor role. Due to the high risk of developing cholangiocarcinoma and also other tumours of the GI tract, surveillance strategies are essential, however they have yet to be established and evaluated. Biochemical parameters, clinical risk factors, endoscopic procedures and imaging techniques contribute to the early identification of patients at risk. Since medical therapy of PSC with ursodeoxycholic acid does not improve survival, to date, liver transplantation is the only option with a cure potential; if transplantation is accurately timed, transplanted PSC patients have an excellent rate of survival. However if cholangiocarcinoma is detected, a curative treatment is not possible in the majority of cases. The present review critically summarizes the current knowledge on the aetiopathogenesis of PSC and gives an overview of the diagnostic approaches, surveillance strategies and therapeutic options. Primary sclerosing cholangitis is a disease of unknown aetiology and without any further curative treatment options apart from liver transplantation. Therefore it may be regarded as the greatest challenge in hepatology today.
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19
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Abstract
Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease of unknown etiology but lymphocytic portal tract infiltration is suggestive of an immune-mediated basis for this disease. Associations with inflammatory bowel disease (IBD) especially ulcerative colitis (UC), and with particular autoimmune diseases, as well as the genetic associations further suggest PSC may be an immune-mediated disease. The immunogenetics of PSC have been the subject of active research and several HLA and non-HLA associated genes have been implicated in the development of the disease. Lymphocytes derived from the inflamed gut may enter the liver via the enterohepatic circulation to cause hepatic disease. PSC may be triggered in genetically susceptible individuals by infections or toxins entering the portal circulation through a permeable colon and hence evoking an abnormal immune response.
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20
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Abstract
This article gives an overview of the molecular and cellular mechanisms of cholestasis. Topics reviewed include the pathomechanisms of hereditary cholestasis syndromes, such as progressive familial intrahepatic cholestasis, and hepatocellular transporter defects encountered in various acquired cholestatic disorders, such as intrahepatic cholestasis of pregnancy, drug-induced cholestasis, inflammatory cholestasis, primary sclerosing cholangitis, and primary biliary cirrhosis. In addition, current concepts regarding adaptive hepatocellular mechanisms counteracting cholestatic liver damage are discussed.
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Affiliation(s)
- Gernot Zollner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Laboratory of Experimental and Molecular Hepatology, Medical University of Graz, Auenbruggerplatz 15, A-8036 Graz, Austria
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21
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Trauner M, Fickert P, Halilbasic E, Moustafa T. Lessons from the toxic bile concept for the pathogenesis and treatment of cholestatic liver diseases. Wien Med Wochenschr 2008; 158:542-8. [PMID: 18998069 DOI: 10.1007/s10354-008-0592-1] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Accepted: 01/07/2008] [Indexed: 01/03/2023]
Abstract
Alterations in bile secretion at the hepatocellular and cholangiocellular levels may cause cholestasis. Formation of 'toxic bile' may be the consequence of abnormal bile composition and can result in hepatocellular and/or bile duct injury. The canalicular phospholipid flippase (Mdr2/MDR3) normally mediates biliary excretion of phospholipids, which normally form mixed micelles with bile acids and cholesterol to protect the bile duct epithelium from the detergent properties of bile acids. Mdr2 knockout mice are not capable of excreting phospholipids into bile and spontaneously develop bile duct injury with macroscopic and microscopic features closely resembling human sclerosing cholangitis. MDR3 mutations have been linked to a broad spectrum of hepatobiliary disorders in humans ranging from progressive familial intrahepatic cholestasis in neonates to intrahepatic cholestasis of pregnancy, drug-induced cholestasis, intrahepatic cholelithiasis, sclerosing cholangitis and biliary cirrhosis in adults. Other examples for bile injury due to the formation of toxic bile include the cholangiopathy seen in cystic fibrosis, after lithocholate feeding (in mice) and vanishing bile duct syndromes induced by drugs and xenobiotics. Therapeutic strategies for cholangiopathies may target bile composition/toxicity and the affected bile duct epithelium itself, and ideally should also have anti-cholestatic, anti-fibrotic and anti-neoplastic properties. Ursodeoxycholic acid (UDCA) shows some of these properties, but is of limited efficacy in the treatment of human cholangiopathies. By contrast to UDCA, its side chain-shortened homologue norUDCA undergoes cholehepatic shunting leading to a bicarbonate-rich hypercholeresis. Moreover, norUDCA has anti-inflammatory, anti-fibrotic and anti-proliferative effects, and stimulates bile acid detoxification. Upcoming clinical trials will have to demonstrate whether norUDCA or other side chain-modified bile acids are also clinically effective in humans. Finally, drugs for the treatment of cholangiopathies may target bile toxicity via nuclear receptors (FXR, PPARalpha) regulating biliary phospholipid and bile acid excretion.
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MESH Headings
- ATP Binding Cassette Transporter, Subfamily B/genetics
- Animals
- Bile/physiology
- Bile Acids and Salts/toxicity
- Bile Canaliculi/physiopathology
- Bile Duct Neoplasms/genetics
- Bile Duct Neoplasms/physiopathology
- Bile Ducts, Intrahepatic/physiopathology
- Carcinoma, Hepatocellular/genetics
- Carcinoma, Hepatocellular/physiopathology
- Cell Transformation, Neoplastic/genetics
- Cholangiocarcinoma/genetics
- Cholangiocarcinoma/physiopathology
- Cholangitis, Sclerosing/genetics
- Cholangitis, Sclerosing/physiopathology
- Cholestasis, Intrahepatic/genetics
- Cholestasis, Intrahepatic/physiopathology
- Cholic Acids
- Disease Models, Animal
- Humans
- Liver Neoplasms/genetics
- Liver Neoplasms/physiopathology
- Mice
- Mice, Knockout
- Mutation/genetics
- Norsteroids
- Ursodeoxycholic Acid/physiology
- ATP-Binding Cassette Sub-Family B Member 4
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Affiliation(s)
- Michael Trauner
- Laboratory of Experimental and Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.
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22
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Abstract
The aetiology of primary sclerosing cholangitis (PSC) is not known. A more than 80-fold increased risk of PSC among first-degree relatives emphasizes the importance of genetic factors. Genetic associations within the human leukocyte antigen (HLA) complex on chromosome 6p21 were detected in PSC 25 years ago. Subsequent studies have substantiated beyond doubt that one or more genetic variants located within this genetic region are important. The true identities of these variants, however, remain to be identified. Several candidate genes at other chromosomal loci have also been investigated. However, according to strict criteria for what may be denominated a susceptibility gene in complex diseases, no such gene exists for PSC today. This review summarises present knowledge on the genetic susceptibility to PSC, as well as genetic associations with disease progression and clinical subsets of particular interest (inflammatory bowel disease and cholangiocarcinoma).
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MESH Headings
- Bile Duct Neoplasms/genetics
- Bile Duct Neoplasms/immunology
- Bile Ducts, Intrahepatic/immunology
- Cholangiocarcinoma/genetics
- Cholangiocarcinoma/immunology
- Cholangitis, Sclerosing/complications
- Cholangitis, Sclerosing/epidemiology
- Cholangitis, Sclerosing/genetics
- Cholangitis, Sclerosing/immunology
- Chromosomes, Human, Pair 6
- Data Interpretation, Statistical
- Disease Progression
- Effect Modifier, Epidemiologic
- Genetic Predisposition to Disease
- HLA Antigens/genetics
- Humans
- Inflammatory Bowel Diseases/genetics
- Inflammatory Bowel Diseases/immunology
- Odds Ratio
- Pedigree
- Polymorphism, Genetic
- Risk Assessment
- Risk Factors
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Affiliation(s)
- Tom-H Karlsen
- Medical Department, Rikshospitalet-Radiumhospitalet Medical Center, N-0027 Oslo, Norway.
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23
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Pall H, Zielenski J, Jonas MM, DaSilva DA, Potvin KM, Yuan XW, Huang Q, Freedman SD. Primary sclerosing cholangitis in childhood is associated with abnormalities in cystic fibrosis-mediated chloride channel function. J Pediatr 2007; 151:255-9. [PMID: 17719933 DOI: 10.1016/j.jpeds.2007.03.062] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2006] [Revised: 02/12/2007] [Accepted: 03/30/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine whether primary sclerosing cholangitis (PSC) in childhood is associated with abnormalities in cystic fibrosis transmembrane conductance regulator (CFTR). STUDY DESIGN Subjects with PSC diagnosed in childhood (n = 20) were recruited from Children's Hospital. Subjects had testing with sweat chloride concentration, nasal transmembrane potential difference, and extensive genetic analysis of the CFTR gene. Disease control subjects consisted of 14 patients with inflammatory bowel disease alone and no liver disease. t tests were performed to determine statistical significance. RESULTS In the PSC group, CFTR chloride channel function (deltaChloride free + isoproterenol) was markedly diminished at -8.6 +/- 8.2 mV (reference range: -24.6 +/- 10.4 mV). In contrast, disease control subjects had normal function, at -17.8 +/- 9.7 mV (P = .008). Sweat chloride concentration in subjects with PSC was greater than in disease control subjects (20.8 +/- 3.4 mmol/L vs 12.0 +/- 1.6 mmol/L, P = .045). Comprehensive CFTR genotyping revealed that 5 of 19 (26.3%) subjects with PSC had a CFTR mutation or variant, compared with 6 of 14 (42.9%) disease control subjects. CONCLUSIONS There is a high prevalence of CFTR-mediated ion transport dysfunction in subjects with childhood PSC.
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Affiliation(s)
- Harpreet Pall
- Division of Pediatric Gastroenterology, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA.
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24
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Black DD. What is the role of cystic fibrosis transmembrane conductance regulator dysfunction in primary sclerosing cholangitis? J Pediatr 2007; 151:230-2. [PMID: 17719926 DOI: 10.1016/j.jpeds.2007.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Accepted: 05/11/2007] [Indexed: 12/12/2022]
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Abstract
Secondary sclerosing cholangitis (SSC) is a disease that is morphologically similar to primary sclerosing cholangitis (PSC) but that originates from a known pathological process. Its clinical and cholangiographic features may mimic PSC, yet its natural history may be more favorable if recognition is prompt and appropriate therapy is introduced. Thus, the diagnosis of PSC requires the exclusion of secondary causes of sclerosing cholangitis and recognition of associated conditions that may potentially imitate its classic cholangiographic features. Well-described causes of SSC include intraductal stone disease, surgical or blunt abdominal trauma, intra-arterial chemotherapy, and recurrent pancreatitis. However, a wide variety of other associations have been reported recently, including autoimmune pancreatitis, portal biliopathy, eosinophillic and/or mast cell cholangitis, hepatic inflammatory pseudotumor, recurrent pyogenic cholangitis, primary immune deficiency, and AIDS-related cholangiopathy. This article offers a comprehensive review of SSC.
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Affiliation(s)
- Rupert Abdalian
- Department of Medicine, University Health Network, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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26
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LaRusso NF, Shneider BL, Black D, Gores GJ, James SP, Doo E, Hoofnagle JH. Primary sclerosing cholangitis: summary of a workshop. Hepatology 2006; 44:746-64. [PMID: 16941705 DOI: 10.1002/hep.21337] [Citation(s) in RCA: 202] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Primary sclerosing cholangitis (PSC) is a rare but important liver disease that leads to cirrhosis and need for liver transplantation in a high proportion of cases. The disease occurs in approximately 1 per 100,000 population per year, usually presents in adulthood, and affects men more often than women. Typical serum biochemical results, autoantibodies and liver biopsy are suggestive but not diagnostic of PSC, the diagnosis requiring cholangiographic demonstration of stricturing and dilatation of the intra- and/or extra-hepatic bile ducts. The natural history of PSC is variable, the average survival being 12 to 17 years. The cause of PSC is still unknown. Although considered an autoimmune disease, PSC has several atypical features and a strong genetic component. The therapy of PSC is unsatisfactory. Standard doses of ursodeoxycholic acid (UDCA) lead to improvements in biochemical abnormalities but not in histology, cholangiographic appearance or survival. Several innovative therapies have been tried in PSC, but with scant evidence of benefit. For patients with high grade strictures, endoscopic dilatation is beneficial. Liver transplantation is successful for end-stage liver disease due to PSC and improves survival. PSC may recur after transplantation but is rarely progressive. The most dreaded complication of PSC is cholangiocarcinoma. Diagnosis of this highly malignant tumor is difficult, and there are no biomarkers for its early detection. Liver transplantation for cholangiocarcinoma has an exceedingly poor outcome, although transplantation with neoadjuvant chemoirradiation holds promise in selected patients. Thus, significant opportunities remain for basic and clinical research into the cause, natural history, and therapy of PSC.
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Affiliation(s)
- Nicholas F LaRusso
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
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27
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Abstract
PURPOSE OF REVIEW Primary sclerosing cholangitis is a chronic cholestatic liver disease characterized by strictures of the biliary tree complicated by cirrhosis and cholangiocarcinoma. It is immune mediated although the precise etiology remains unknown. RECENT FINDINGS Research into etiopathogenesis, epidemiology, the relationship with inflammatory bowel disease, diagnosis of cholangiocarcinoma, medical therapy, and the outcome of liver transplantation are discussed. SUMMARY It is likely that a number of patients previously diagnosed with primary sclerosing cholangitis have autoimmune pancreatitis in association with primary sclerosing cholangitis, a syndrome with distinct clinicopathological features including steroid responsiveness. Primary sclerosing cholangitis-inflammatory bowel disease probably represents a distinct inflammatory bowel disease phenotype, which has implications for colonoscopic surveillance of these patients. CA19-9 plays no surveillance role for the early detection of cholangiocarcinoma. The best-studied drug in primary sclerosing cholangitis is ursodeoxycholic acid, which, despite a range of potentially valuable actions on the cholestatic liver, has not yet been proved to make a substantial impression on the course of the disease. Orthotopic liver transplantation remains the only established long-term treatment for primary sclerosing cholangitis.
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Affiliation(s)
- George R MacFaul
- Department of Gastroenterology, John Radcliffe Hospital, Oxford, UK
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28
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Abstract
PURPOSE OF REVIEW This review highlights recent advances in understanding the regulation of bile acid transport in cholestasis and in the pathogenesis, outcomes, epidemiology, and treatment of a variety of cholestatic liver diseases and their associated complications. RECENT FINDINGS Highlights include additional understanding of the role of the nuclear receptors farsenoid X receptor, pregnane X receptor, and constitutive androstane receptor in bile acid homeostasis, new understanding of the pathogenesis of primary biliary cirrhosis, familial intrahepatic cholestasis, biliary atresia, and primary sclerosing cholangitis, and clinical trials of therapies for intrahepatic cholestasis of pregnancy, primary biliary cirrhosis, and primary sclerosing cholangitis. SUMMARY Our understanding of the molecular mechanisms, epidemiology and pathogenesis of cholestasis continues to advance. These advances will hopefully lead to more effective therapies for specific cholestatic conditions.
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Affiliation(s)
- Anna E Rutherford
- Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, 02114, USA
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Pall H, Zaman MM, Andersson C, Freedman SD. Decreased peroxisome proliferator activated receptor alpha is associated with bile duct injury in cystic fibrosis transmembrane conductance regulator-/- mice. J Pediatr Gastroenterol Nutr 2006; 42:275-81. [PMID: 16540796 DOI: 10.1097/01.mpg.0000189368.37535.42] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is associated with mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. As proof of concept that CFTR dysfunction plays a role in PSC, induction of colitis in cftr mice results in bile duct injury that can be prevented by pretreatment with docosahexaenoic acid (DHA). OBJECTIVES Determine whether 1) CFTR dysfunction in cftr mice through a reduction in peroxisome proliferator activated receptor (PPAR)alpha or gamma leads to bile duct injury and 2) whether DHA prevents bile duct injury through an increase in PPAR. METHODS Cftr and wild-type (WT) mice were treated with dextran sodium sulfate (DSS) to induce colitis with or without pretreatment with oral DHA. PPARalpha and gamma as well as tumor necrosis factor (TNF)alpha were analyzed in liver tissue. PPARalpha mice were also treated with DSS and histology examined. RESULTS PPARgamma mRNA levels were low, with DSS suppressing mRNA levels equally in WT and cftr mice. PPARalpha levels were no different between cftr and WT litter mates by reverse-transcription polymerase chain reaction. After DSS, WT mice showed a 9.3-fold increase in PPARalpha mRNA levels and increased nuclear localization compared with no DSS (P < 0.05), with no increase seen in cftr mice. This was not caused by changes in TNFalpha. DHA treatment led to 7.0-fold increase in PPARalpha mRNA levels in cftr mice (P < 0.01). PPARalpha mice treated with DSS did not develop bile duct injury, indicating that PPARalpha alone is not sufficient to cause bile duct inflammation. CONCLUSION DSS induced bile duct injury in cftr mice is associated with a defect in PPARalpha expression, which is reversed by DHA.
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Affiliation(s)
- Harpreet Pall
- Division of Pediatric Gastroenterology, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA
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