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Chung PHY, Harumatsu T, Nakagawa Y, Tsuboi K, Chan EKW, Leung MWY, Yeung F, Muto M, Kawano T, Amano H, Shirota C, Nakamura H, Koga H, Miyano G, Yamataka A, Ieiri S, Uchida H, Wong KKY. Cholestasis after Kasai operation predicts portal hypertension in native liver survivors of biliary atresia: a multicenter study. Pediatr Surg Int 2024; 40:196. [PMID: 39017953 PMCID: PMC11254997 DOI: 10.1007/s00383-024-05775-0] [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] [Accepted: 07/06/2024] [Indexed: 07/18/2024]
Abstract
PURPOSE This study evaluated portal hypertension (PHT) and its predictors among native liver survivors (NLS) of biliary atresia (BA) after Kasai portoenterostomy (KPE). METHODS This was a multicenter study using prospectively collected data. The subjects were patients who remained transplant-free for 5 years after KPE. Their status of PHT was evaluated and variables that predicted PHT were determined by regression analysis and receiver operating characteristic (ROC) curve. RESULTS Six centers from East Asia participated in this study and 320 subjects with KPE between 1980 to 2018 were analyzed. The mean follow-up period was 10.6 ± 6.2 years. At the 5th year after KPE, PHT was found in 37.8% of the subjects (n = 121). Patients with KPE done before day 41 of life had the lowest percentage of PHT compared to operation at older age. At 12 months after KPE, PHT + ve subjects had a higher bilirubin level (27.1 ± 11.7 vs 12.3 ± 7.9 µmol/L, p = 0.000) and persistent jaundice conferred a higher risk for PHT (OR = 12.9 [9.2-15.4], p = 0.000). ROC analysis demonstrated that a bilirubin level above 38 µmol/L at 12 months after KPE predicted PHT development (sensitivity: 78%, specificity: 60%, AUROC: 0.75). CONCLUSIONS In BA, early KPE protects against the development of PHT among NLSs. Patients with persistent cholestasis at one year after KPE are at a higher risk of this complication. They should receive a more vigilant follow-up. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Patrick Ho Yu Chung
- Division of Paediatric Surgery, Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, HKSAR, People's Republic of China
| | - Toshio Harumatsu
- Department of Pediatric Surgery, Kagoshima University, Kagoshima, Japan
| | - Yoichi Nakagawa
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Koichi Tsuboi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Edwin Kin Wai Chan
- Division of Pediatric Surgery and Pediatric Urology, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, HKSAR, People's Republic of China
| | - Michael Wai Yip Leung
- Department of Surgery, Hong Kong Children's Hospital, Hong Kong, HKSAR, People's Republic of China
| | - Fanny Yeung
- Division of Paediatric Surgery, Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, HKSAR, People's Republic of China
| | - Mitsuru Muto
- Department of Pediatric Surgery, Kagoshima University, Kagoshima, Japan
| | - Takafumi Kawano
- Department of Pediatric Surgery, Kagoshima University, Kagoshima, Japan
| | - Hizuru Amano
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Nakamura
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Go Miyano
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Satoshi Ieiri
- Department of Pediatric Surgery, Kagoshima University, Kagoshima, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenneth Kak Yuen Wong
- Division of Paediatric Surgery, Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, HKSAR, People's Republic of China.
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van Hooff MC, Werner E, van der Meer AJ. Treatment in primary biliary cholangitis: Beyond ursodeoxycholic acid. Eur J Intern Med 2024; 124:14-21. [PMID: 38307734 DOI: 10.1016/j.ejim.2024.01.030] [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: 10/10/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 02/04/2024]
Abstract
Primary biliary cholangitis (PBC) is a rare cholestatic immune-mediated liver disease. The clinical course varies from mild to severe, with a substantial group of patients developing cirrhosis within a decade. These patients are at risk of hepatocellular carcinoma, decompensation and liver failure. First line Ursodeoxycholic acid (UDCA) treatment improves the cholestatic surrogate markers, and was recently associated with a favorable survival free of liver transplantation, even in case of an incomplete biochemical response. However, despite adequate UDCA therapy, patients remain at risk of liver disease progression. Therefore, on-treatment multifactor-based risk stratification is necessary to identify patients in need of additional therapy. This requires a personalized approach; especially as recent studies suggest that complete biochemical normalization as most stringent response criterion might be preferred in selected patients to optimize their outcome. Today, stricter biochemical goals might actually be reachable with the addition of farnesoid X receptor or peroxisome proliferator-activated receptor agonists, or, in highly-selected cases, use of corticosteroids. Randomized controlled trials showed improvements in the key biochemical surrogate markers with the addition of these drugs, which have also been associated with improved clinical outcome. Considering this evolving PBC landscape, with more versatile treatment options and treatment goals, this review recapitulates the recent insight in UDCA therapy, the selection of patients with a residual risk of liver disease progression and the results of the currently available second line treatment options.
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Affiliation(s)
- M C van Hooff
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, NA building, Floor 6, Rotterdam 3015 GD, the Netherlands
| | - E Werner
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, NA building, Floor 6, Rotterdam 3015 GD, the Netherlands
| | - A J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, NA building, Floor 6, Rotterdam 3015 GD, the Netherlands.
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Hofer BS, Burghart L, Halilbasic E, Simbrunner B, Petrenko O, Mandorfer M, Stättermayer AF, Trauner M, Reiberger T. Evaluation of potential hepatic recompensation criteria in patients with PBC and decompensated cirrhosis. Aliment Pharmacol Ther 2024; 59:962-972. [PMID: 38409879 DOI: 10.1111/apt.17908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 11/25/2023] [Accepted: 02/06/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Aetiological therapy improves liver function and may enable hepatic recompensation in decompensated cirrhosis. AIMS We explored the potential for recompensation in patients with decompensated primary biliary cholangitis (PBC) - considering a biochemical response to ursodeoxycholic acid (UDCA) according to Paris-II criteria as a surrogate for successful aetiological treatment. METHODS Patients with PBC were retrospectively included at the time of first decompensation. Recompensation was defined as (i) resolution of ascites and hepatic encephalopathy (HE) despite discontinuation of diuretic/HE therapy, (ii) absence of variceal bleeding and (iii) sustained liver function improvement. RESULTS In total, 42 patients with PBC with decompensated cirrhosis (age: 63.5 [IQR: 51.9-69.2] years; 88.1% female; MELD-Na: 13.5 [IQR: 11.0-15.0]) were included and followed for 41.9 (IQR: 11.0-70.9) months after decompensation. Seven patients (16.7%) achieved recompensation. Lower MELD-Na (subdistribution hazard ratio [SHR]: 0.90; p = 0.047), bilirubin (SHR per mg/dL: 0.44; p = 0.005) and alkaline phosphatase (SHR per 10 U/L: 0.67; p = 0.001) at decompensation, as well as variceal bleeding as decompensating event (SHR: 4.37; p = 0.069), were linked to a higher probability of recompensation. Overall, 33 patients were treated with UDCA for ≥1 year and 12 (36%) achieved Paris-II response criteria. Recompensation occurred in 5/12 (41.7%) and in 2/21 (9.5%) patients with vs. without UDCA response at 1 year, respectively. Recompensation was linked to a numerically improved transplant-free survival (HR: 0.46; p = 0.335). Nonetheless, 4/7 recompensated patients presented with liver-related complications after developing hepatic malignancy and/or portal vein thrombosis and 2 eventually died. CONCLUSIONS Patients with PBC and decompensated cirrhosis may achieve hepatic recompensation under UDCA therapy. However, since liver-related complications still occur after recompensation, patients should remain under close follow-up.
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Affiliation(s)
- Benedikt Silvester Hofer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
| | - Lukas Burghart
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
- Klinik Ottakring, Wiener Gesundheitsverbund, Vienna, Austria
| | - Emina Halilbasic
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
| | - Oleksandr Petrenko
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
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Ding D, Ren P, Guo G, Liu Y, Yang C, Zheng L, Jia G, Deng J, Sun R, Wang X, Zhou X, Shang Y, Han Y. Fenofibrate normalizes alkaline phosphatase and improves long-term outcomes in patients with advanced primary biliary cholangitis refractory to ursodeoxycholic acid. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:692-701. [PMID: 36632973 DOI: 10.1016/j.gastrohep.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND Although patients with advanced liver disease have been included in studies evaluating fibrates for the treatment of primary biliary cholangitis (PBC), the frequency of biochemical responses and adverse effects for this group of patients was not reported separately and comprehensively. AIMS to evaluate the efficacy and safety of additional fenofibrate therapy in patients with advanced and ursodeoxycholic acid (UDCA)-refractory PBC. METHODS Patients were analyzed retrospectively to determine the clinical therapeutic effects of UDCA with additional fenofibrate therapy versus continued UDCA monotherapy. The liver transplantation (LT)-free survival and the alkaline phosphatase (ALP) normalization rates were estimated using Cox regression analyses and Kaplan-Meier plots with inverse probability of treatment weighting (IPTW). RESULTS A total of 118 patients were included: 54 received UDCA alone and 64 received UDCA in combination with fenofibrate therapy. In the fenofibrate and UDCA groups, 37% and 11% of patients with advanced and UDCA-refractory PBC, respectively, achieved ALP normalization (P=0.001). Additional fenofibrate therapy improved both LT-free survival and ALP normalization rate after IPTW (hazard ratio [HR]: 0.23, 95% confidence interval [CI]: 0.07-0.75, P=0.015; and HR: 11.66, 95% CI: 5.02-27.06, P=0.001, respectively). These effects were supported by parallel changes in the rates of liver decompensation and histologic progression, and the United Kingdom (UK)-PBC and Globe risk scores. During the follow-up period, serum levels of ALP and aminotransferase decreased significantly, while total bilirubin, albumin, platelet, serum creatinine, and estimated glomerular filtration rate remained stable in fenofibrate-treated participants. No fenofibrate-related significant adverse events were observed in our cohort. CONCLUSIONS Additional fenofibrate therapy significantly improved LT-free survival and ALP normalization in patients with advanced and UDCA-refractory PBC. Furthermore, adding-on fenofibrate therapy appeared to be safe and well tolerated in this population.
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Affiliation(s)
- Dawei Ding
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Pengwei Ren
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Guanya Guo
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yansheng Liu
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Chunmei Yang
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Linhua Zheng
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Gui Jia
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Juan Deng
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Ruiqing Sun
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiufang Wang
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xinmin Zhou
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China.
| | - Yulong Shang
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China.
| | - Ying Han
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China.
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Zhang H, Li S, Feng Y, Zhang Q, Xie B. Efficacy of fibrates in the treatment of primary biliary cholangitis: a meta-analysis. Clin Exp Med 2023; 23:1741-1749. [PMID: 36318376 DOI: 10.1007/s10238-022-00904-2] [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: 08/29/2022] [Accepted: 09/21/2022] [Indexed: 03/12/2023]
Abstract
Patients with primary biliary cholangitis (PBC) who respond poorly to ursodeoxycholic acid (UDCA) are increasingly being trialed using fibrates, showing promising results. To further investigate, we performed a meta-analysis to evaluate the benefit of administrating fibrates to patients with PBC. PubMed, EMBASE, and Cochrane library databases were searched using the keywords "bezafibrate", "fenofibrate", "fibrate", "primary biliary cholangitis" and clinical studies involving the use of fibrates in patients with PBC were included. The primary outcome of this study was the effect of fibrates administration on biochemical markers related to cholestasis in patients with PBC, and the secondary outcome was the incidence of treatment-related adverse events. A total of 20 studies with 4783 participants were included in this study. The results revealed that adding fibrates could significantly reduce the levels of ALP (fibrates vs. placebo, MD: - 370.14, P = 0.04; fibrates + UDCA vs. UDCA, MD: - 184.15, P < 0.01), total cholesterol (MD: - 2.82, P = 0.04), GGT (fibrates vs. placebo, MD: - 140.88, P < 0.01; fibrates + UDCA vs. UDCA, MD: - 130.73, P = 0.04), alleviate pruritus symptoms (RD: - 0.20, 95% CI: - 0.39 ~ - 0.01, P = 0.04), and did not significantly increase the incidence of treatment-related side effects. Fibrates can significantly improve liver biochemical parameters and alleviate pruritus in PBC patients.
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Affiliation(s)
- Haifu Zhang
- Internal Medicine, The First Hospital of Fuyang, Hangzhou, 311400, Zhejiang, China
| | - Shuojun Li
- Internal Medicine, The First Hospital of Fuyang, Hangzhou, 311400, Zhejiang, China
| | - Yonghang Feng
- Internal Medicine, The First Hospital of Fuyang, Hangzhou, 311400, Zhejiang, China
| | - Qinxia Zhang
- Internal Medicine, The First Hospital of Fuyang, Hangzhou, 311400, Zhejiang, China
| | - Biyun Xie
- Internal Medicine, The First Hospital of Fuyang, Hangzhou, 311400, Zhejiang, China.
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Levy C, Manns M, Hirschfield G. New Treatment Paradigms in Primary Biliary Cholangitis. Clin Gastroenterol Hepatol 2023; 21:2076-2087. [PMID: 36809835 DOI: 10.1016/j.cgh.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/28/2023] [Accepted: 02/03/2023] [Indexed: 02/24/2023]
Abstract
Primary biliary cholangitis (PBC) is an archetypal autoimmune disease. Chronic lymphocytic cholangitis is associated with interface hepatitis, ductopenia, cholestasis, and progressive biliary fibrosis. People living with PBC are frequently symptomatic, experiencing a quality-of-life burden dominated by fatigue, itch, abdominal pain, and sicca complex. Although the female predominance, specific serum autoantibodies, immune-mediated cellular injury, as well as genetic (HLA and non-HLA) risk factors, identify PBC as autoimmune, to date treatment has focused on cholestatic consequences. Biliary epithelial homeostasis is abnormal and contributes to disease. The impact of cholangiocyte senescence, apoptosis, and impaired bicarbonate secretion enhances chronic inflammation and bile acid retention. First-line therapy is a non-specific anti-cholestatic agent, ursodeoxycholic acid. For those with residual cholestasis biochemically, obeticholic acid is introduced, and this semisynthetic farnesoid X receptor agonist adds choleretic, anti-fibrotic, and anti-inflammatory activity. Future PBC licensed therapy will likely include peroxisome proliferator activated receptor (PPAR) pathway agonists, including specific PPAR-delta agonism (seladelpar), as well as elafibrinor and saroglitazar (both with broader PPAR agonism). These agents dovetail the clinical and trial experience for off-label bezafibrate and fenofibrate use. Symptom management is essential, and encouragingly, PPAR agonists reduce itch; IBAT inhibition (eg, linerixibat) also appears promising for pruritus. For those where liver fibrosis is the target, NOX inhibition is being evaluated. Earlier stage therapies in development include therapy to impact immunoregulation in patients, as well other approaches to treating pruritus (eg, antagonists of MrgprX4). Collectively the PBC therapeutic landscape is exciting. Therapy goals are increasingly proactive and individualized and aspire to rapidly achieve normal serum tests and quality of life with prevention of end-stage liver disease.
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Affiliation(s)
- Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami School of Medicine, Miami, Florida.
| | | | - Gideon Hirschfield
- Toronto Centre for Liver Disease, Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Canada
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You H, Duan W, Li S, Lv T, Chen S, Lu L, Ma X, Han Y, Nan Y, Xu X, Duan Z, Wei L, Jia J, Zhuang H. Guidelines on the Diagnosis and Management of Primary Biliary Cholangitis (2021). J Clin Transl Hepatol 2023; 11:736-746. [PMID: 36969891 PMCID: PMC10037524 DOI: 10.14218/jcth.2022.00347] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/02/2022] [Accepted: 11/20/2022] [Indexed: 03/29/2023] Open
Abstract
In 2015, the Chinese Society of Hepatology and the Chinese Society of Gastroenterology published a consensus on primary biliary cholangitis (PBC). In the past years, numerous clinical studies have been published in the field of PBC. To guide the clinical diagnosis and management of PBC patients, the Chinese Society of Hepatology invited a panel of experts to assess the new clinical evidence and formulate the current guidelines.
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Affiliation(s)
- Hong You
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Weijia Duan
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Shuxiang Li
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Tingting Lv
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Sha Chen
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Lungen Lu
- Department of Gastroenterology, First People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiong Ma
- Department of Gastroenterology and Hepatology, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ying Han
- Department of Gastroenterology, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi, China
| | - Yuemin Nan
- Department of Traditional and Western Medical Hepatology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xiaoyuan Xu
- Department of Infectious Diseases and Center for Liver Diseases, Peking University First Hospital, Beijing, China
- Correspondence to: Jidong Jia, Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Road, Beijing 100050, China. ORCID: https://orcid.org/0000-0002-4673-8890. Tel: +86-10-63139816, Fax: +86-10-63139246, E-mail: ; Xiaoyuan Xu, Department of Infectious Diseases, Peking University First Hospital, Beijing 100034, China. ORCID: https://orcid.org/0000-0002-1759-4330. Tel/Fax: +86-10-83575787, E-mail:
| | - Zhongping Duan
- Artificial Liver Center, Beijing You-An Hospital, Capital Medical University, Beijing, China
| | - Lai Wei
- Hepatobiliary Pancreatic Center, Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing, China
- Correspondence to: Jidong Jia, Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Road, Beijing 100050, China. ORCID: https://orcid.org/0000-0002-4673-8890. Tel: +86-10-63139816, Fax: +86-10-63139246, E-mail: ; Xiaoyuan Xu, Department of Infectious Diseases, Peking University First Hospital, Beijing 100034, China. ORCID: https://orcid.org/0000-0002-1759-4330. Tel/Fax: +86-10-83575787, E-mail:
| | - Hui Zhuang
- Department of Microbiology and Infectious Disease Center, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
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Trivella J, John BV, Levy C. Primary biliary cholangitis: Epidemiology, prognosis, and treatment. Hepatol Commun 2023; 7:02009842-202306010-00027. [PMID: 37267215 DOI: 10.1097/hc9.0000000000000179] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/10/2023] [Indexed: 06/04/2023] Open
Abstract
Primary biliary cholangitis (PBC) is a chronic cholestatic autoimmune liver disease characterized by a destructive, small duct, and lymphocytic cholangitis, and marked by the presence of antimitochondrial antibodies. The incidence and prevalence of PBC vary widely in different regions and time periods, and although disproportionally more common among White non-Hispanic females, contemporary data show a higher prevalence in males and racial minorities than previously described. Outcomes largely depend on early recognition of the disease and prompt institution of treatment, which, in turn, are directly influenced by provider bias and socioeconomic factors. Ursodeoxycholic acid remains the initial treatment of choice for PBC, with obeticholic acid and fibrates (off-label therapy) reserved as add-on therapy for the management of inadequate responders or those with ursodeoxycholic acid intolerance. Novel and repurposed drugs are currently at different stages of clinical development not only for the treatment of PBC but also for its symptomatic management. Here, we summarize the most up-to-date data regarding the epidemiology, prognosis, and treatment of PBC, providing clinically useful information for its holistic management.
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Affiliation(s)
- Juan Trivella
- Department of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Binu V John
- Department of Medicine, Division of Gastroenterology and Hepatology, Miami VA Medical System, Miami, Florida, USA
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Cynthia Levy
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
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Gao Y, Xun R, Xia J, Xia H, Sun G. Effects of phytosterol supplementation on lipid profiles in patients with hypercholesterolemia: a systematic review and meta-analysis of randomized controlled trials. Food Funct 2023; 14:2969-2997. [PMID: 36891733 DOI: 10.1039/d2fo03663k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Phytosterols (PSs) have been reported to improve blood lipids in patients with hypercholesterolemia for many years. However, meta-analyses of the effects of phytosterols on lipid profiles are limited and incomplete. A systematic search of randomized controlled trials (RCTs) published in PubMed, Embase, Cochrane Library, and Web of Science from inception to March 2022 was conducted according to the 2020 preferred reporting items of the guidelines for systematic reviews and meta-analysis (PRISMA) statement. These included studies of people with hypercholesterolemia, comparing foods or preparations containing PSs with controls. Mean differences with 95% confidence intervals were used to estimate continuous outcomes for individual studies. The results showed that in patients with hypercholesterolemia, taking a diet containing a certain dose of plant sterol significantly reduced total cholesterol (TC) and low density lipoprotein cholesterol (LDL-C) (TC: Weight Mean Difference (WMD) [95% CI] = -0.37 [-0.41, -0.34], p < 0.001; LDL-C: WMD [95% CI] = -0.34 [-0.37, -0.30], p < 0.001). In contrast, PSs had no effect on high density lipoprotein cholesterol (HDL-C) or triglycerides (TGs) (HDL-C: WMD [95% CI] = 0.00 [-0.01, 0.02], p = 0.742; TG: WMD [95% CI] = -0.01 [-0.04, 0.01], p = 0.233). Also, a significant effect of supplemental dose on LDL-C levels was observed in a nonlinear dose-response analysis (p-nonlinearity = 0.024). Our findings suggest that dietary phytosterols can help reduce TC and LDL-C concentrations in hypercholesterolemia patients without affecting HDL-C and TG concentrations. And the effect may be affected by the food substrate, dose, esterification, intervention cycle and region. The dose of phytosterol is an important factor affecting the level of LDL-C.
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Affiliation(s)
- Yusi Gao
- Key Laboratory of Environmental Medicine and Engineering of Ministry of Education, Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, Nanjing 210009, China.
| | - Ruilong Xun
- Key Laboratory of Environmental Medicine and Engineering of Ministry of Education, Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, Nanjing 210009, China.
| | - Jiayue Xia
- Key Laboratory of Environmental Medicine and Engineering of Ministry of Education, Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, Nanjing 210009, China.
| | - Hui Xia
- Key Laboratory of Environmental Medicine and Engineering of Ministry of Education, Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, Nanjing 210009, China.
| | - Guiju Sun
- Key Laboratory of Environmental Medicine and Engineering of Ministry of Education, Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, Nanjing 210009, China. .,China-DRIs Expert Committee on Other Dietary Ingredients, Beijing 100052, China
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10
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Tamai H, Okamura J. Safety and efficacy of switching to pemafibrate from bezafibrate in patients with chronic liver disease. Hepatol Res 2023; 53:258-266. [PMID: 36378065 DOI: 10.1111/hepr.13859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/02/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022]
Abstract
AIM Although fibrates were developed as lipid-lowering drugs, their efficacy against liver dysfunction in patients with cholestatic liver diseases, such as primary biliary cholangitis, primary sclerosing cholangitis, and fatty liver disease, has also been reported. Although fibrates act on some peroxisome proliferator-activated receptors (PPARs), pemafibrate is a novel selective PPAR-α modulator. The present study aimed to evaluate the safety and efficacy of switching from bezafibrate to pemafibrate in patients with chronic liver disease. METHODS We analyzed 58 patients with chronic liver disease who switched from bezafibrate to pemafibrate because of minor adverse effects and/or incomplete response. RESULTS This study included 41 patients with cholestatic liver disease and 17 patients with non-alcoholic fatty liver disease. Reasons for switching to pemafibrate were renal function decline in 31 patients, hemoglobin decline in 17 patients, creatine kinase (CK) elevation in 11 patients, incomplete response of liver dysfunction in 39 patients, and incomplete response of hyperlipidemia in 13 patients. After 3 months, although no significant change in CK was seen, hemoglobin and estimated glomerular filtration rate were significantly increased, and creatinine was significantly decreased. Significant decreases in hepatobiliary enzymes were seen in patients with cholestatic liver diseases, but not in patients with non-alcoholic fatty liver disease. No significant changes in serum lipids were observed. No patients discontinued pemafibrate due to adverse events. CONCLUSIONS Switching to pemafibrate could improve adverse effects due to bezafibrate, and appeared effective against liver dysfunction in cholestatic liver disease patients with incomplete response to bezafibrate.
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Affiliation(s)
- Hideyuki Tamai
- Department of Hepatology, Wakayama Rosai Hospital, Wakayama, Japan
| | - Jumpei Okamura
- Department of Hepatology, Wakayama Rosai Hospital, Wakayama, Japan
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11
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Application of the Latest Advances in Evidence-Based Medicine in Primary Biliary Cholangitis. Am J Gastroenterol 2023; 118:232-242. [PMID: 36729104 PMCID: PMC9889200 DOI: 10.14309/ajg.0000000000002070] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 09/23/2022] [Indexed: 02/03/2023]
Abstract
Primary biliary cholangitis (PBC) is a chronic, cholestatic, autoimmune liver disease that can progress to end-stage liver disease and its complications. A previous expert review panel collaborated on a consensus document for gastroenterologists and other healthcare professionals regarding the care of patients with PBC. Subsequently, there have been several recent important developments in the diagnosis, treatment, and monitoring of patients with PBC. These include updates to prognostic models on risk stratification, new noninvasive tools for staging of disease, updates to the appropriate use of and long-term treatment results with obeticholic acid as a second-line treatment, the emerging therapeutic role of fibrates, and the advancement of investigational agents for managing PBC. In this updated expert consensus document, we provide updates on staging, the use of noninvasive prognostic tools, and a treatment algorithm to provide evidence-based and practical tools for clinicians who manage PBC, with the ultimate goal to improve the long-term outcomes for patients with this chronic liver disease.
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12
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Nevens F, Trauner M, Manns MP. Primary biliary cholangitis as a roadmap for the development of novel treatments for cholestatic liver diseases †. J Hepatol 2023; 78:430-441. [PMID: 36272496 DOI: 10.1016/j.jhep.2022.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 10/07/2022] [Accepted: 10/07/2022] [Indexed: 11/16/2022]
Abstract
The discovery of nuclear receptors and transporters has contributed to the development of new drugs for the treatment of cholestatic liver diseases. Particular progress has been made in the development of second-line therapies for PBC. These new drugs can be separated into compounds primarily targeting cholestasis, molecules targeting fibrogenesis and molecules with immune-mediated action. Finally, drugs aimed at symptom relief (pruritus and fatigue) are also under investigation. Obeticholic acid is currently the only approved second-line therapy for PBC. Drugs in the late phase of clinical development include peroxisome proliferator-activated receptor agonists, norursodeoxycholic acid and NADPH oxidase 1/4 inhibitors.
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Affiliation(s)
- Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospital KU Leuven, Belgium; Centre of ERN RARE-LIVER.
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Austria; Centre of ERN RARE-LIVER
| | - Michael P Manns
- Hannover Medical School, Hannover, Germany; Centre of ERN RARE-LIVER
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13
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Li Y, Tian C, Song X, Du M, Zhang G, Liu H. New IMB16-4 Hot-Melt Extrusion Preparation Improved Oral Bioavailability and Enhanced Anti-Cholestatic Effect on Rats. Drug Des Devel Ther 2023; 17:649-657. [PMID: 36879928 PMCID: PMC9985389 DOI: 10.2147/dddt.s395114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/16/2023] [Indexed: 03/04/2023] Open
Abstract
Background Cholestasis is challenging to treat due to lacked effective drugs. N-(3,4,5-trichlorophenyl)-2 (3-nitrobenzenesulfonamido) benzamide, abbreviated as IMB16-4, which may be effective for the treatment of cholestasis. However, its poor solubility and bioavailability seriously obstruct the research programs. Methods A hot-melt extrusion (HME) preparation was first applied to increase the bioavailability of IMB16-4, the oral bioavailability, anti-cholestatic effect and vitro cytotoxicity of IMB16-4 and IMB16-4-HME were evaluated. Meanwhile, the molecular docking and qRT-PCR were used to validate the mechanism behind. Results The oral bioavailability of IMB16-4-HME improved 65-fold compared with that of pure IMB16-4. Pharmacodynamics results demonstrated that IMB16-4-HME prominently decreased the serum levels of total bile acid (TBA) and alkaline phosphatase (ALP), but elevated the level of total bilirubin (TBIL) and direct bilirubin (DBIL). Histopathology revealed that IMB16-4-HME at lower dose exhibited stronger anti-cholestatic effect compared with pure IMB16-4. In addition, molecular docking demonstrated that IMB16-4 has great affinity with PPARα, and qRT-PCR results revealed that IMB16-4-HME significantly elevated the mRNA expression level of PPARα, but decreased the mRNA level of CYP7A1. Cytotoxicity assays demonstrated that the hepatotoxicity of IMB16-4-HME was absolutely attributed to IMB16-4, and the excipients of IMB16-4-HME may increase the drug load within HepG2 cells. Conclusion The HME preparation significantly increased the oral bioavailability and anti-cholestatic effect of pure IMB16-4, but caused liver injury at high dose, which require a dose balance between the curative effect and safety in the future research.
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Affiliation(s)
- Yuqin Li
- Graduate School, Hebei Medical University, Shijiazhuang, People's Republic of China.,Hebei Key Laboratory of Metabolic Diseases, Hebei General Hospital, Shijiazhuang, People's Republic of China
| | - Changlin Tian
- Graduate School, Hebei Medical University, Shijiazhuang, People's Republic of China.,Hebei Key Laboratory of Metabolic Diseases, Hebei General Hospital, Shijiazhuang, People's Republic of China
| | - Xiaofei Song
- Department of Otolaryngology, Hebei General Hospital, Shijiazhuang, People's Republic of China
| | - Mengying Du
- Performance Assessment Department, Quality Management Department, Hebei General Hospital, Shijiazhuang, People's Republic of China
| | - Guoning Zhang
- Institute of Medicinal Biotechnology, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Hongtao Liu
- Hebei Key Laboratory of Metabolic Diseases, Hebei General Hospital, Shijiazhuang, People's Republic of China
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14
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Lawitz EJ, Bhandari BR, Ruane PJ, Kohli A, Harting E, Ding D, Chuang JC, Huss RS, Chung C, Myers RP, Loomba R. Fenofibrate Mitigates Hypertriglyceridemia in Nonalcoholic Steatohepatitis Patients Treated With Cilofexor/Firsocostat. Clin Gastroenterol Hepatol 2023; 21:143-152.e3. [PMID: 34999207 DOI: 10.1016/j.cgh.2021.12.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/21/2021] [Accepted: 12/24/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with advanced fibrosis due to nonalcoholic steatohepatitis (NASH) are at high risk of morbidity and mortality. We previously found that a combination of the farnesoid X receptor agonist cilofexor (CILO) and the acetyl-CoA carboxylase inhibitor firsocostat (FIR) improved liver histology and biomarkers in NASH with advanced fibrosis but was associated with hypertriglyceridemia. We evaluated the safety and efficacy of icosapent ethyl (Vascepa) and fenofibrate to mitigate triglyceride elevations in patients with NASH treated with CILO and FIR. METHODS Patients with NASH with elevated triglycerides (≥150 and <500 mg/dL) were randomized to Vascepa 2 g twice daily (n = 33) or fenofibrate 145 mg daily (n = 33) for 2 weeks, followed by the addition of CILO 30 mg and FIR 20 mg daily for 6 weeks. Safety, lipids, and liver biochemistry were monitored. RESULTS All treatments were well-tolerated; most treatment-emergent adverse events were Grade 1 to 2 severity, and there were no discontinuations due to adverse events. At baseline, median (interquartile range [IQR]) triglycerides were similar in the Vascepa and fenofibrate groups (median, 177 [IQR, 154-205] vs 190 [IQR, 144-258] mg/dL, respectively). Median changes from baseline in triglycerides for Vascepa vs fenofibrate after 2 weeks of pretreatment were -12 mg/dL (IQR, -33 to 7 mg/dL; P = .09) vs -32 mg/dL (IQR, -76 to 6 mg/dL; P = .012) and at 6 weeks were +41 mg/dL (IQR, 16-103 mg/dL; P < .001) vs -2 mg/dL (IQR, -42 to 54 mg/dL; P = .92). In patients with baseline triglycerides <250 mg/dL, fenofibrate was more effective vs Vascepa in mitigating triglyceride increases after 6 weeks of combination treatment (+6 vs +39 mg/dL); similar trends were observed in patients with baseline triglycerides ≥250 mg/d (-61 vs +99 mg/dL). CONCLUSIONS In patients with NASH with hypertriglyceridemia treated with CILO and FIR, fenofibrate was safe and effectively mitigated increases in triglycerides associated with acetyl-CoA carboxylase inhibition. CLINICALTRIALS gov, Number: NCT02781584.
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Affiliation(s)
- Eric J Lawitz
- Texas Liver Institute and University of Texas Health, San Antonio, Texas
| | | | - Peter J Ruane
- Ruane Clinical Research Group, Inc, Los Angeles, California
| | | | | | - Dora Ding
- Gilead Sciences, Inc, Foster City, California
| | | | - Ryan S Huss
- Gilead Sciences, Inc, Foster City, California
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15
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Chen Y, Yang S, Liu L, Yang X, Duan Y, Zhang S, Han J. A novel therapy for hepatic cholestasis treatment-the combination of rosiglitazone and fenofibrate. Eur J Pharmacol 2022; 938:175428. [PMID: 36436592 DOI: 10.1016/j.ejphar.2022.175428] [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: 08/03/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 11/26/2022]
Abstract
Hepatic cholestasis can develop into liver fibrosis and eventually liver failure. Currently, ursodeoxycholic acid (UDCA) or UDCA combined with fenofibrate is used for cholestasis treatment. Rosiglitazone inhibited α-naphthyl isothiocyanate (ANIT)-induced cholestasis in mice. In this study, we compared the effect of rosiglitazone, UDCA, fenofibrate, combined rosiglitazone and fenofibrate or UDCA and fenofibrate on ANIT-induced cholestasis. C57BL/6J mice were induced cholestasis by ANIT while treated with rosiglitazone, UDCA, fenofibrate, combination of rosiglitazone and fenofibrate, or combination of UDCA and fenofibrate. Liver and serum samples were collected to determine liver necrosis and serum biochemical parameters. Rosiglitazone alone or combined with fenofibrate demonstrated better effects than UDCA alone or UDCA combined with fenofibrate in reduction of cholestasis-induced serum biochemical parameters and liver necrosis. Surprisingly, UDCA combined with fenofibrate, but not rosiglitazone combined with fenofibrate, potently increased accumulation of free fatty acids (FFAs) in the liver. Mechanistically, the protection of combination of rosiglitazone and fenofibrate against cholestasis was attributed to activated adiponectin pathway to enhance FXR and mitochondrial functions and reduce apoptosis in the liver. The accumulation of FFAs in the liver by combination of UDCA and fenofibrate was caused by activation of fatty acid biosynthesis and uptake, and triglyceride hydrolysis. Taken together, our study not only demonstrates the adverse effect of combination therapy of UDCA and fenofibrate, but also suggests the combination of rosiglitazone and fenofibrate can be another option for cholestasis treatment.
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Affiliation(s)
- Yuanli Chen
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Shu Yang
- Department of Geriatrics, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China; College of Life Sciences, Key Laboratory of Bioactive Materials of Ministry of Education, State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, China
| | - Lipei Liu
- College of Life Sciences, Key Laboratory of Bioactive Materials of Ministry of Education, State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, China
| | - Xiaoxiao Yang
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Yajun Duan
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Shuang Zhang
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, China.
| | - Jihong Han
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, College of Food and Biological Engineering, Hefei University of Technology, Hefei, China; College of Life Sciences, Key Laboratory of Bioactive Materials of Ministry of Education, State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, China.
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16
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Liu CH, Bowlus CL. Treatment of Primary Biliary Cholangitis: First-Line and Second-Line Therapies. Clin Liver Dis 2022; 26:705-726. [PMID: 36270725 DOI: 10.1016/j.cld.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Primary biliary cholangitis (PBC) is an autoimmune disease of the interlobular bile ducts leading to secondary damage of hepatocytes and may progress to cirrhosis and liver failure. The first-line treatment is ursodeoxycholic acid; up to 40% of patients do not have an adequate response and remain at risk of disease progression. Obeticholic acid has been conditionally approved for the treatment of PBC as add-on therapy and bezafibrate has shown similar efficacy in this group of patients. Several new therapies are in development and may further add to the treatment options available to patients with PBC.
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Affiliation(s)
- Chung-Heng Liu
- Drexel University College of Medicine, 2900 W Queen Ln, Philadelphia, PA 19129 USA
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, 4150 V Street, PSSB 3500, Sacramento, CA 95817, USA.
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17
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Ding D, Guo G, Liu Y, Zheng L, Jia G, Deng J, Sun R, Wang X, Guo C, Shang Y, Han Y. Efficacy and safety of fenofibrate addition therapy in patients with cirrhotic primary biliary cholangitis with incomplete response to ursodeoxycholic acid. Hepatol Commun 2022; 6:3487-3495. [PMID: 36213941 PMCID: PMC9701475 DOI: 10.1002/hep4.2103] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/15/2022] [Accepted: 09/01/2022] [Indexed: 01/21/2023] Open
Abstract
Fenofibrate (FF) has shown potential benefits in patients with primary biliary cholangitis (PBC) who have an incomplete response to ursodeoxycholic acid (UDCA). However, the efficacy and safety of FF in patients with cirrhosis remain unclear. To evaluate the efficacy and safety of additional FF therapy in patients with PBC-related cirrhosis with an incomplete response to UDCA, we conducted a retrospective analysis comparing the clinical results of additional FF therapy and continued UDCA monotherapy. A total of 59 patients were included; 27 cases underwent UDCA monotherapy and 32 cases underwent UDCA combined with FF therapy. A significant difference in alkaline phosphatase (ALP) normalization was achieved in the FF group compared to the UDCA group (37% vs. 11%, respectively; p = 0.020). Additional FF therapy was an independent risk factor for ALP normalization (hazard ratio, 7.679; 95% confidence interval, 2.059-28.633; p = 0.003). Hepatic deterioration was experienced by 40% versus 48% (p = 0.562) while 11% vs. 37% (p = 0.111) experienced liver-related mortality or liver transplantation in the FF and UDCA groups, respectively. Compared to UDCA monotherapy, additional FF therapy was associated with lower United Kingdom (UK)-PBC risk score and surrogate serum indices of liver fibrosis. After 12 months of add-on FF therapy, median ALP level and UK-PBC risk score decreased 35% and 52% from baseline (p = 0.001 and 0.210, respectively). Serum aminotransferase, triglyceride, and cholesterol decreased progressively, while total bilirubin, serum creatinine, blood urea, estimated glomerular filtration rate, aspartate aminotransferase-to-platelet ratio index, and fibrosis-4 index remained stable in FF-treated cirrhotic cases during follow-up. No significant adverse effects associated with additional FF therapy were observed in our cohort. Conclusion: Additional FF therapy was associated with higher ALP normalization rates and lower UK-PBC risk scores in patients with cirrhotic PBC with an incomplete response to UDCA. In addition, FF therapy seemed safe and well tolerated with a low frequency of adverse effects in patients with cirrhosis.
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Affiliation(s)
- Dawei Ding
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Guanya Guo
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Yansheng Liu
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Linhua Zheng
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Gui Jia
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Juan Deng
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Ruiqing Sun
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Xiufang Wang
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Changcun Guo
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Yulong Shang
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
| | - Ying Han
- State Key Laboratory of Cancer BiologyXijing Hospital of Digestive Diseases, The Air Force Military Medical UniversityXi'anChina
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18
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Efficacy and Safety of Bezafibrate Alone or in Combination with Ursodeoxycholic Acid in Primary Biliary Cholangitis: Systematic Review and Meta-Analysis. Dig Dis Sci 2022; 68:1559-1573. [PMID: 36180756 DOI: 10.1007/s10620-022-07704-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 09/16/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Bezafibrate (BZF) alone or in combination with ursodeoxycholic acid (UDCA) has been used to slow disease progression in patients with primary biliary cholangitis (PBC). We performed a systematic review and meta-analysis to assess the efficacy and harms of BZF monotherapy or combination therapy. METHODS We performed a systematic search of PubMed, EMBASE, Cochrane Library, Scopus, ClinicalTrials.gov, and WHO ICTRP from inception until January 2020, for randomized controlled clinical trials assessing BZF + UDCA versus UDCA monotherapy or BZF monotherapy versus UDCA monotherapy in PBC patients. Additionally, we systematically evaluated data on harms using seven observational studies. Pooled effect estimates were calculated for the outcomes of interest. The certainty of evidence was assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). RESULTS We identified 7 randomized controlled trials with a total of 279 participants. Comparing BZF + UDCA to UDCA alone, a clinically significant improvement was observed in serum ALP with a mean difference (MD) of - 159.04 U/L (95% CI - 186.45 to - 131.62) and a reduction in gamma-glutamyltransferase (GGT) (MD - 106.94 IU/L; 95% CI - 151.99 to - 61.89), but not in total bilirubin (TB) or IgM levels. A statistically significant reduction in ALP levels was also noticed with BZF monotherapy compared to UDCA monotherapy. The effect of BZF + UDCA versus UDCA on mortality remains unclear. Across 5 observational studies including 106 patients, one death was reported due to advanced liver disease in an incomplete responder getting treatment with BZF + UDCA. Analysis of observational studies demonstrated improvement in pruritus intensity with BZF. CONCLUSIONS Use of BZF alone or in combination with UDCA improved liver biochemistries in patients with PBC, but its effect on mortality, liver-related complications or quality of life remains unknown.
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Suppression of Hepatic PPARα in Primary Biliary Cholangitis Is Modulated by miR-155. Cells 2022; 11:cells11182880. [PMID: 36139455 PMCID: PMC9496720 DOI: 10.3390/cells11182880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/08/2022] [Accepted: 09/10/2022] [Indexed: 12/12/2022] Open
Abstract
Background: PPARα is a ligand-activated transcription factor that shows protective effects against metabolic disorders, inflammation and apoptosis. Primary biliary cholangitis and primary sclerosing cholangitis result in the intrahepatic accumulation of bile acids that leads to liver dysfunction and damage. Small, non-coding RNAs such as miR-155 and miR-21 are associated with silencing PPARα. Methods: The expression of miR-155, miR-21 and PPARα were evaluated using real-time PCR on liver tissue, as well as on human hepatocytes (HepG2) or cholangiocytes (NHCs) following exposure to lipopolysaccharide (LPS), glycodeoxycholic acid (GCDCA), lithocholic acid (LCA) and/or ursodeoxycholic acid (UDCA). Results: A reduction of PPARα in primary biliary cholangitis (PBC) livers was associated with miR-21 and miR-155 upregulation. Experimental overexpression of either miR-155 or miR-21 inhibited PPARα in hepatocytes, whereas, in cholangiocytes, only miR-21 suppressed PPARα. Both GCDCA and LCA induced the cell type-specific upregulation of miR-155 or miR-21. In HepG2, LPS-induced miR-155 expression was blocked by a cotreatment with UDCA and was associated with PPARα upregulation. In NHC cells, the expression of miR-21 was induced by LPS but did not affect PPARα expression. Conclusions: Hepatic PPARα expression is reduced in PBC livers as a likely result of miR-155 overexpression. UDCA effectively reduced both baseline and LPS-induced miR-155 expression, thus preventing the suppression of PPARα.
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20
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Cançado GGL, Couto CA, Guedes LV, Braga MH, Terrabuio DRB, Cançado ELR, Ferraz MLG, Villela-Nogueira CA, Nardelli MJ, Faria LC, de Oliveira EMG, Rotman V, Mazo DFDC, Borges VFDAE, Mendes LSC, Codes L, Pessoa MG, Signorelli IV, Levy C, Bittencourt PL. Fibrates for the Treatment of Primary Biliary Cholangitis Unresponsive to Ursodeoxycholic Acid: An Exploratory Study. Front Pharmacol 2022; 12:818089. [PMID: 35126149 PMCID: PMC8811361 DOI: 10.3389/fphar.2021.818089] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/15/2021] [Indexed: 12/12/2022] Open
Abstract
Aim: Up to 40% of patients with primary biliary cholangitis (PBC) will have a suboptimal biochemical response to ursodeoxycholic acid (UDCA), which can be improved by the addition of fibrates. This exploratory study aims to evaluate the long-term real-life biochemical response of different fibrates, including ciprofibrate, in subjects with UDCA-unresponsive PBC. Methods: The Brazilian Cholestasis Study Group multicenter database was reviewed to assess the response rates to UDCA plus fibrates in patients with UDCA-unresponsive PBC 1 and 2 years after treatment initiation by different validated criteria. Results: In total, 27 patients (100% women, mean age 48.9 ± 9.2 years) with PBC were included. Overall response rates to fibrates by each validated criterion varied from 39 to 60% and 39–76% at 12 and 24 months after treatment combination, respectively. Combination therapy resulted in a significant decrease in ALT and ALP only after 2 years, while GGT significantly improved in the first year of treatment. Treatment response rates at 1 and 2 years appear to be comparable between ciprofibrate and bezafibrate using all available criteria. Conclusion: Our findings endorse the efficacy of fibrate add-on treatment in PBC patients with suboptimal response to UDCA. Ciprofibrate appears to be at least as effective as bezafibrate and should be assessed in large clinical trials as a possibly new, cheaper, and promising option for treatment of UDCA-unresponsive PBC patients.
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Affiliation(s)
- Guilherme Grossi Lopes Cançado
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Hospital da Polícia Militar de Minas Gerais, Belo Horizonte, Brazil
- *Correspondence: Guilherme Grossi Lopes Cançado,
| | - Cláudia Alves Couto
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Laura Vilar Guedes
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Michelle Harriz Braga
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | - Cristiane Alves Villela-Nogueira
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mateus Jorge Nardelli
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Luciana Costa Faria
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Vivian Rotman
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Daniel Ferraz de Campos Mazo
- Divisão de Gastroenterologia (Gastrocentro), Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, Brazil
| | | | | | - Liana Codes
- Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
- Hospital Português, Salvador, Brazil
| | - Mario Guimarães Pessoa
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Paulo Lisboa Bittencourt
- Hospital Português, Salvador, Brazil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil
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21
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Gallucci GM, Trottier J, Hemme C, Assis DN, Boyer JL, Barbier O, Ghonem NS. Adjunct Fenofibrate Up-regulates Bile Acid Glucuronidation and Improves Treatment Response For Patients With Cholestasis. Hepatol Commun 2021; 5:2035-2051. [PMID: 34558841 PMCID: PMC8631103 DOI: 10.1002/hep4.1787] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/10/2021] [Accepted: 06/25/2021] [Indexed: 12/26/2022] Open
Abstract
Accumulation of cytotoxic bile acids (BAs) during cholestasis can result in liver failure. Glucuronidation, a phase II metabolism pathway responsible for BA detoxification, is regulated by peroxisome proliferator-activated receptor alpha (PPARα). This study investigates the efficacy of adjunct fenofibrate therapy to up-regulate BA-glucuronidation and reduce serum BA toxicity during cholestasis. Adult patients with primary biliary cholangitis (PBC, n = 32) and primary sclerosing cholangitis (PSC, n = 23), who experienced an incomplete response while receiving ursodiol monotherapy (13-15 mg/kg/day), defined as serum alkaline phosphatase (ALP) ≥ 1.5 times the upper limit of normal, received additional fenofibrate (145-160 mg/day) as standard of care. Serum BA and BA-glucuronide concentrations were measured by liquid chromatography-mass spectrometry. Combination therapy with fenofibrate significantly decreased elevated serum ALP (-76%, P < 0.001), aspartate transaminase, alanine aminotransferase, bilirubin, total serum BAs (-54%), and increased serum BA-glucuronides (+2.1-fold, P < 0.01) versus ursodiol monotherapy. The major serum BA-glucuronides that were favorably altered following adjunct fenofibrate include hyodeoxycholic acid-6G (+3.7-fold, P < 0.01), hyocholic acid-6G (+2.6-fold, P < 0.05), chenodeoxycholic acid (CDCA)-3G (-36%), and lithocholic acid (LCA)-3G (-42%) versus ursodiol monotherapy. Fenofibrate also up-regulated the expression of uridine 5'-diphospho-glucuronosyltransferases and multidrug resistance-associated protein 3 messenger RNA in primary human hepatocytes. Pearson's correlation coefficients identified strong associations between serum ALP and metabolic ratios of CDCA-3G (r2 = 0.62, P < 0.0001), deoxycholic acid (DCA)-3G (r2 = 0.48, P < 0.0001), and LCA-3G (r2 = 0.40, P < 0.001), in ursodiol monotherapy versus control. Receiver operating characteristic analysis identified serum BA-glucuronides as measures of response to therapy. Conclusion: Fenofibrate favorably alters major serum BA-glucuronides, which correlate with reduced serum ALP levels and improved outcomes. A PPARα-mediated anti-cholestatic mechanism is involved in detoxifying serum BAs in patients with PBC and PSC who have an incomplete response on ursodiol monotherapy and receive adjunct fenofibrate. Serum BA-glucuronides may serve as a noninvasive measure of treatment response in PBC and PSC.
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Affiliation(s)
- Gina M. Gallucci
- College of Pharmacy, Biomedical and Pharmaceutical SciencesUniversity of Rhode IslandKingstonRIUSA
| | - Jocelyn Trottier
- Laboratory of Molecular PharmacologyEndocrinology and Nephrology AxisCHU de Québec Research CenterLavalQuébecCanada
| | - Christopher Hemme
- College of Pharmacy, Biomedical and Pharmaceutical SciencesUniversity of Rhode IslandKingstonRIUSA
- RI‐INBRE Bioinformatics CoreKingstonRIUSA
| | | | | | - Olivier Barbier
- Laboratory of Molecular PharmacologyEndocrinology and Nephrology AxisCHU de Québec Research CenterLavalQuébecCanada
- Faculty of PharmacyLaval UniversityLavalQuébecCanada
| | - Nisanne S. Ghonem
- College of Pharmacy, Biomedical and Pharmaceutical SciencesUniversity of Rhode IslandKingstonRIUSA
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