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Sankararaman S, Freeman AJ. Early detection of hepatobiliary involvement in cystic fibrosis: Biomarkers, radiologic methods, and genetic influences. Pediatr Pulmonol 2024; 59 Suppl 1:S107-S114. [PMID: 39105338 DOI: 10.1002/ppul.26892] [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: 08/14/2023] [Revised: 01/10/2024] [Accepted: 01/21/2024] [Indexed: 08/07/2024]
Abstract
Cystic fibrosis-related hepatobiliary involvement (CFHBI) is a term used to describe a spectrum of hepatobiliary involvement ranging from a transient elevation of transaminase levels to advanced cystic fibrosis-associated liver disease (aCFLD). While CFHBI is common among people with cystic fibrosis (PwCF), aCFLD is rare impacting only approximately 5%-10% of the CF population. After respiratory/cardiorespiratory issues and transplant-related complications, aCFLD is now the 4th leading cause of mortality among PwCF. Additionally, aCFLD is an independent predictor of all-cause mortality and is associated with significant morbidity. Despite this recognition, our ability to predict those patients at greatest risk for aCFLD, identify early aCFLD, and monitor the incremental progression of CFHBI is lacking. Here, we review the strengths and weaknesses of the common biomarkers and imaging modalities used in the evaluation and monitoring of CFHBI, as well as the current understanding of genetic modifiers related to aCFLD.
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Affiliation(s)
- Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
- Case Western Reserve University SOM, Cleveland, Ohio, USA
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Nationwide Children's Hospital, Columbus, Ohio, USA
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2
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Ferraioli G, Barr RG, Berzigotti A, Sporea I, Wong VWS, Reiberger T, Karlas T, Thiele M, Cardoso AC, Ayonrinde OT, Castera L, Dietrich CF, Iijima H, Lee DH, Kemp W, Oliveira CP, Sarin SK. WFUMB Guideline/Guidance on Liver Multiparametric Ultrasound: Part 1. Update to 2018 Guidelines on Liver Ultrasound Elastography. ULTRASOUND IN MEDICINE & BIOLOGY 2024; 50:1071-1087. [PMID: 38762390 DOI: 10.1016/j.ultrasmedbio.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 05/20/2024]
Abstract
The World Federation for Ultrasound in Medicine and Biology (WFUMB) endorsed the development of this document on multiparametric ultrasound. Part 1 is an update to the WFUMB Liver Elastography Guidelines Update released in 2018 and provides new evidence on the role of ultrasound elastography in chronic liver disease. The recommendations in this update were made and graded using the Oxford classification, including level of evidence (LoE), grade of recommendation (GoR) and proportion of agreement (Oxford Centre for Evidence-Based Medicine [OCEBM] 2009). The guidelines are clinically oriented, and the role of shear wave elastography in both fibrosis staging and prognostication in different etiologies of liver disease is discussed, highlighting advantages and limitations. A comprehensive section is devoted to the assessment of portal hypertension, with specific recommendations for the interpretation of liver and spleen stiffness measurements in this setting.
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Affiliation(s)
- Giovanna Ferraioli
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Richard Gary Barr
- Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio, USA; Southwoods Imaging, Youngstown, Ohio, USA
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ioan Sporea
- Division of Gastroenterology and Hepatology, Department of Internal Medicine II, Center for Advanced Research in Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, Timișoara, Romania
| | - Vincent Wai-Sun Wong
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China; State Key Laboratory of Digestive Disease, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, China
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Thomas Karlas
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Maja Thiele
- Center for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department for Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ana Carolina Cardoso
- Hepatology Division, School of Medicine, Federal University of Rio de Janeiro, Clementino, Fraga Filho Hospital, Rua Prof. Rodolpho Paulo Rocco, Cidade Universitária da Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Oyekoya Taiwo Ayonrinde
- Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia; Medical School, University of Western Australia, Crawley, Western Australia, Australia; Curtin Medical School, Curtin University, Kent Street, Bentley, Western Australia, Australia
| | - Laurent Castera
- Université Paris-Cité, Inserm UMR1149, Centre de Recherche sur l'Inflammation, Paris, France; Service d'Hépatologie, Hôpital Beaujon, Assistance-Publique Hôpitaux de Paris, Clichy, France
| | - Christoph Frank Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem and Permancence, Bern, Switzerland
| | - Hiroko Iijima
- Division of Hepatobiliary and Pancreatic Disease, Department of Gastroenterology, Hyogo Medical University, Nishinomiya, Hyogo, Japan; Ultrasound Imaging Center, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - William Kemp
- Department of Gastroenterology, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Claudia P Oliveira
- Gastroenterology Department, Laboratório de Investigação (LIM07), Hospital das Clínicas de São Paulo, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
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Wood W, Tinich T, Lazar L, Schooler GR, Sathe M. Cystic fibrosis hepatobiliary involvement: an update on imaging in diagnosis and monitoring. Pediatr Radiol 2024; 54:1416-1427. [PMID: 39039200 DOI: 10.1007/s00247-024-05979-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/16/2024] [Accepted: 06/19/2024] [Indexed: 07/24/2024]
Abstract
Analysis of the liver using imaging for persons with cystic fibrosis (CF) continues to evolve as new medical therapies are developed improving and extending life. In the 2010s, therapies targeted at modulating protein folding became available to those with CF. Therapeutic options have continued to expand, now providing both correction of protein folding and stabilization for most gene mutations that code for the CF transmembrane receptor protein (CFTR). Today, approximately 80% of persons with CF are eligible for highly effective modulator therapy. With these advancements, the impact of CF on the liver has become more complex, adding metabolism of CFTR modulators to intrinsic CF hepatobiliary involvement (CFHBI) and adding not previously appreciated vascular changes within the liver due to increased longevity in persons with CF. A combination of serum biomarkers and imaging is needed to add clarity to the diagnosis and monitoring of the severity of liver disease. A substantial portion of persons with CF will develop at least CFHBI and a subset will develop advanced cystic fibrosis-associated liver disease (aCFLD); therefore, diagnosis and monitoring need to begin in childhood. In this review, we cover the use of and need for imaging, including elastography, ultrasound, and magnetic resonance imaging (MRI), in diagnosing and monitoring CFHBI and its associated complications.
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Affiliation(s)
- William Wood
- Pediatric Residency, Department of Pediatrics, University of Texas Southwestern/Children's Health, Dallas, TX, USA
| | - Treiy Tinich
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Lauren Lazar
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Texas Southwestern Medical Center/Children's Health, Dallas, TX, 75390-9063, USA
| | - Gary R Schooler
- Department of Radiology, University of Texas Southwestern/Children's Health, Dallas, TX, USA
| | - Meghana Sathe
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Texas Southwestern Medical Center/Children's Health, Dallas, TX, 75390-9063, USA.
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Sellers ZM, Assis DN, Paranjape SM, Sathe M, Bodewes F, Bowen M, Cipolli M, Debray D, Green N, Hughan KS, Hunt WR, Leey J, Ling SC, Morelli G, Peckham D, Pettit RS, Philbrick A, Stoll J, Vavrina K, Allen S, Goodwin T, Hempstead SE, Narkewicz MR. Cystic fibrosis screening, evaluation, and management of hepatobiliary disease consensus recommendations. Hepatology 2024; 79:1220-1238. [PMID: 37934656 PMCID: PMC11020118 DOI: 10.1097/hep.0000000000000646] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/11/2023] [Indexed: 11/09/2023]
Abstract
Cystic fibrosis (CF) may cause a spectrum of hepatobiliary complications, including portal hypertension, multilobular cirrhosis, and liver failure. Current guidelines on the detection and monitoring of hepatobiliary complications in CF were published in 1999. The CF Foundation assembled a committee to evaluate research advances and formulate revised guidelines for CF-associated liver disease. A committee of hepatologists, gastroenterologists, pulmonologists, pharmacists, nurses, dietitians, individuals with CF, and the parents of a child with CF devised "population, intervention, comparison, and outcome" questions regarding hepatobiliary disease in CF. PubMed literature searches were performed for each population, intervention, comparison, and outcome question. Recommendations were voted on with 80% agreement required to approve a recommendation. Public comment on initial recommendations was solicited prior to the formulation of final recommendations. Thirty-one population, intervention, comparison, and outcome questions were assembled, 6401 manuscripts were title screened for relevance, with 1053 manuscripts undergoing detailed full-text review. Seven recommendations were approved for screening, 13 for monitoring of existing disease, and 14 for treatment of CF-associated hepatobiliary involvement or advanced liver disease. One recommendation on liver biopsy did not meet the 80% threshold. One recommendation on screening ultrasound was revised and re-voted on. Through a multidisciplinary committee and public engagement, we have assembled updated recommendations and guidance on screening, monitoring, and treatment of CF-associated hepatobiliary involvement and advanced liver disease. While research gaps remain, we anticipate that these recommendations will lead to improvements in CF outcomes through earlier detection and increased evidence-based approaches to monitoring and treatment.
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Affiliation(s)
- Zachary M. Sellers
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, California, USA
| | - David N. Assis
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Shruti M. Paranjape
- Division of Pediatric Pulmonology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Meghana Sathe
- Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, UT Southwestern, Dallas, Texas, USA
| | - Frank Bodewes
- Department of Pediatric Gastroenterology, University Medical Center Groningen, Groningen, The Netherlands
| | - Melissa Bowen
- Department of Advanced Lung Disease and Lung Transplant, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Dominique Debray
- Pediatric Hepatology Unit, AP-HP, HôpitalNecker-Enfants malades, Paris, France
| | - Nicole Green
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Seattle Children’s Hospital and University of Washington, Seattle, Washington State, USA
| | - Kara S. Hughan
- Department of Pediatrics, Division of Pediatric Endocrinology and Metabolism, UPMC Children’s Hospital of Pittsburgh and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - William R. Hunt
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, Emory University, Atlanta, Georgia, USA
| | - Julio Leey
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, Florida, USA
| | - Simon C. Ling
- Department of Paediatrics, Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Giuseppe Morelli
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Daniel Peckham
- Leeds Institute of Medical Research at St. James’s, University of Leeds, Leeds, UK
| | - Rebeca S. Pettit
- Riley Hospital for Children at IU Health, Indianapolis, Indiana, USA
| | - Alexander Philbrick
- Department of Specialty Pharmacy, Northwestern Medicine, Chicago, Illinois, USA
| | - Janis Stoll
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Washington University School of Medicine, St Louis, Missouri, USA
| | - Kay Vavrina
- University of Texas, Health Science Center, San Antonio, Texas, USA
| | - Stacy Allen
- CF Parent Community Advisor to Cystic Fibrosis Foundation, USA
| | - Tara Goodwin
- CF Parent Community Advisor to Cystic Fibrosis Foundation, USA
| | | | - Michael R. Narkewicz
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, Children’s Hospital Colorado, University of Colorado School of, Aurora, Colorado, USA
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Mittelheisser V, Gensbittel V, Bonati L, Li W, Tang L, Goetz JG. Evidence and therapeutic implications of biomechanically regulated immunosurveillance in cancer and other diseases. NATURE NANOTECHNOLOGY 2024; 19:281-297. [PMID: 38286876 DOI: 10.1038/s41565-023-01535-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 09/26/2023] [Indexed: 01/31/2024]
Abstract
Disease progression is usually accompanied by changes in the biochemical composition of cells and tissues and their biophysical properties. For instance, hallmarks of cancer include the stiffening of tissues caused by extracellular matrix remodelling and the softening of individual cancer cells. In this context, accumulating evidence has shown that immune cells sense and respond to mechanical signals from the environment. However, the mechanisms regulating these mechanical aspects of immune surveillance remain partially understood. The growing appreciation for the 'mechano-immunology' field has urged researchers to investigate how immune cells sense and respond to mechanical cues in various disease settings, paving the way for the development of novel engineering strategies that aim at mechanically modulating and potentiating immune cells for enhanced immunotherapies. Recent pioneer developments in this direction have laid the foundations for leveraging 'mechanical immunoengineering' strategies to treat various diseases. This Review first outlines the mechanical changes occurring during pathological progression in several diseases, including cancer, fibrosis and infection. We next highlight the mechanosensitive nature of immune cells and how mechanical forces govern the immune responses in different diseases. Finally, we discuss how targeting the biomechanical features of the disease milieu and immune cells is a promising strategy for manipulating therapeutic outcomes.
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Affiliation(s)
- Vincent Mittelheisser
- Tumor Biomechanics, INSERM UMR_S1109, Strasbourg, France
- Université de Strasbourg, Strasbourg, France
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
- Equipe Labellisée Ligue Contre le Cancer, Strasbourg, France
| | - Valentin Gensbittel
- Tumor Biomechanics, INSERM UMR_S1109, Strasbourg, France
- Université de Strasbourg, Strasbourg, France
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
- Equipe Labellisée Ligue Contre le Cancer, Strasbourg, France
| | - Lucia Bonati
- Institute of Bioengineering, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Weilin Li
- Institute of Bioengineering, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Li Tang
- Institute of Bioengineering, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland.
- Institute of Materials Science and Engineering, EPFL, Lausanne, Switzerland.
| | - Jacky G Goetz
- Tumor Biomechanics, INSERM UMR_S1109, Strasbourg, France.
- Université de Strasbourg, Strasbourg, France.
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France.
- Equipe Labellisée Ligue Contre le Cancer, Strasbourg, France.
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6
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Lusman SS. Update on Cystic Fibrosis in Pediatric Patients. Curr Gastroenterol Rep 2023; 25:308-315. [PMID: 37653358 DOI: 10.1007/s11894-023-00896-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE OF REVIEW Cystic fibrosis is an inherited, multisystem disease that affects the gastrointestinal system in numerous ways. This article reviews the nutritional, gastrointestinal, and hepatobiliary manifestations of cystic fibrosis with an emphasis on the effects of CFTR modulator therapy. RECENT FINDINGS The life expectancy of individuals with cystic fibrosis has increased substantially in recent years. CFTR modulator therapy improves pulmonary function and results in weight gain. An individualized approach to nutrition is encouraged. Pancreatic exocrine function may improve with intervention early in life. The use of non-invasive methods to screen for hepatobiliary involvement is recommended. Highly effective CFTR modulators lead to increased survival and improved quality of life for many individuals. Their effects on gastrointestinal symptoms and hepatobiliary disease are not fully understood. Patient-reported outcome measures and biomarkers are important clinical endpoints for studying the effects of modulators.
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Affiliation(s)
- Sarah Shrager Lusman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, 622 West 168th Street, PH 17 East - 105L, New York, NY, 10032, USA.
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7
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Towbin AJ, Ye W, Huang S, Karmazyn BW, Molleston JP, Masand P, Leung DH, Chang S, Narkewicz MR, Alazraki AL, Freeman AJ, Otto RK, Green N, Kamel IR, Karnsakul WW, Magee JC, Tkach J, Palermo JJ. Prospective study of quantitative liver MRI in cystic fibrosis: feasibility and comparison to PUSH cohort ultrasound. Pediatr Radiol 2023; 53:2210-2220. [PMID: 37500799 DOI: 10.1007/s00247-023-05706-6] [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: 10/20/2022] [Revised: 06/08/2023] [Accepted: 06/17/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Pediatric radiologists can identify a liver ultrasound (US) pattern predictive of progression to advanced liver disease. However, reliably discriminating these US patterns remains difficult. Quantitative magnetic resonance imaging (MRI) may provide an objective measure of liver disease in cystic fibrosis (CF). OBJECTIVE The purpose of this study was to determine if quantitative MRI, including MR elastography, is feasible in children with CF and to determine how quantitative MRI-derived metrics compared to a research US. MATERIALS AND METHODS A prospective, multi-institutional trial was performed evaluating CF participants who underwent a standardized MRI. At central review, liver stiffness, fat fraction, liver volume, and spleen volume were obtained. Participants whose MRI was performed within 1 year of US were classified by US pattern as normal, homogeneous hyperechoic, heterogeneous, or nodular. Each MRI measure was compared among US grade groups using the Kruskal-Wallis test. RESULTS Ninety-three participants (51 females [54.8%]; mean 15.6 years [range 8.1-21.7 years]) underwent MRI. MR elastography was feasible in 87 participants (93.5%). Fifty-eight participants had an US within 1 year of MRI. In these participants, a nodular liver had significantly higher stiffness (P<0.01) than normal or homogeneous hyperechoic livers. Participants with a homogeneous hyperechoic liver had a higher fat fraction (P<0.005) than others. CONCLUSION MR elastography is feasible in children with CF. Participants with a nodular pattern had higher liver stiffness supporting the US determination of advanced liver disease. Participants with a homogeneous hyperechoic pattern had higher fat fractions supporting the diagnosis of steatosis.
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Affiliation(s)
- Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital, 3333 Burnet Avenue, MLC 5031, Cincinnati, OH, 45229, USA.
- Department of Radiology, University of Cincinnati School of Medicine, Cincinnati, OH, USA.
| | - Wen Ye
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Suiyuan Huang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Boaz W Karmazyn
- Pediatric Radiology, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Prakash Masand
- Division of Radiology, Texas Children's Hospital, Houston, TX, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's, Baylor College of Medicine, Houston, TX, USA
| | - Samuel Chang
- Department of Radiology, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - Michael R Narkewicz
- Digestive Health Institute, Children's Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adina L Alazraki
- Department of Radiology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Randolph K Otto
- Department of Radiology, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Nicole Green
- Division of Gastroenterology and Hepatology, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Ihab R Kamel
- Department of Radiology, John Hopkins School of Medicine, Baltimore, MD, USA
| | - Wikrom W Karnsakul
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, John Hopkins School of Medicine, Baltimore, MD, USA
| | - John C Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jean Tkach
- Department of Radiology, Cincinnati Children's Hospital, 3333 Burnet Avenue, MLC 5031, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Joseph J Palermo
- Division of Pediatric, Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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8
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Sakhuja S, Staples HM, Minard CG, Ramm LE, Lewindon PJ, Ramm GA, Leung DH. Risk factors for more rapid progression of severe liver fibrosis in children with cystic fibrosis-related liver disease: A multi-center study validated by liver biopsy. Liver Int 2023; 43:1277-1286. [PMID: 37035868 DOI: 10.1111/liv.15572] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/15/2023] [Accepted: 03/18/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND AND AIMS Early identification of risk factors for the development of severe fibrosis in children with cystic fibrosis-related liver disease (CFLD) is crucial as promising therapies emerge. METHODS This multi-center cohort study of children with a priori defined CFLD from 1999 to 2016, was designed to evaluate the clinical utility of CF-specific characteristics and liver biomarkers assessed years prior to liver biopsy-proven CFLD to predict risk of developing severe fibrosis (F3-4) over time. Fibrosis was staged by Metavir classification. RESULTS The overall study cohort of 42 patients (F0-2 (n = 22) and F3-4 (n = 20)) was 57% male (n = 24) with median age of 7.6 years at baseline visit versus 10.3 years at biopsy. Median FEV1 % predicted was lower in F3-4 participants at baseline versus F0-2 (59% vs. 85%; p = .002), while baseline FIB-4, APRI and GGT were higher in F3-4. Median splits for FIB-4 (≥.13), APRI (≥.36), GPR (≥.09), GGT (≥25.5), and FEV1 % (<64%) were associated with more rapid progression to F3-4 (p < .01 for all). Using a combination of change/year in FIB-4, APRI, and GPR to predict F3-4, the AUROC was .81 (95% CI, .66, .96; p < .0001). For up to 5.8 years prior, thresholds for GPR were met 6.5-fold more rapidly, and those for APRI and FIB-4 were met 2.5-fold more rapidly, in those who progressed to F3-4 than those that did not. CONCLUSIONS This study suggests mild-moderate pulmonary dysfunction and higher liver biomarker indices at baseline may be associated with faster progression of CFLD.
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Affiliation(s)
- Shruti Sakhuja
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Gastroenterology, Hepatology, Nutrition, Texas Children's Hospital, Houston, Texas, USA
| | - Heather M Staples
- Department of Pediatrics, University of South Carolina School of Medicine, Columbia, South Carolina, USA
- Division of Pediatric Pulmonology, Prisma Health Children's Hospital-Midlands, Columbia, South Carolina, USA
| | - Charles G Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas, USA
| | - Louise E Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Peter J Lewindon
- Department of Gastroenterology, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Grant A Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Daniel H Leung
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Gastroenterology, Hepatology, Nutrition, Texas Children's Hospital, Houston, Texas, USA
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9
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The effects of CFTR modulator therapies on liver stiffness and bile flow: a single centre experience. J Hepatol 2023:S0168-8278(23)00094-6. [PMID: 36804403 DOI: 10.1016/j.jhep.2023.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/01/2023] [Indexed: 02/23/2023]
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10
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Vélez C, Freedman SD, Assis DN. Update in Advancing the Gastrointestinal Frontier in Cystic Fibrosis. Clin Chest Med 2022; 43:743-755. [PMID: 36344078 DOI: 10.1016/j.ccm.2022.07.001] [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: 11/06/2022]
Abstract
Clinical complications of cystic fibrosis (CF) include a variety of gastrointestinal (GI) and hepatobiliary manifestations. Recent years have witnessed several advances in the understanding and management of these complications, in addition to opportunities for therapeutic innovations. Herein we review the current understanding of these disorders and also discuss the management of the GI and hepatobiliary complications experienced by persons with CF.
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Affiliation(s)
- Christopher Vélez
- Division of Gastroenterology, Department of Medicine, Center for Neurointestinal Health, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street Suite 535, Boston, MA 0211, USA
| | - Steven D Freedman
- Beth Israel Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - David N Assis
- Section of Digestive Diseases, Yale School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06510, USA.
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11
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Dana J, Girard M, Franchi-Abella S, Berteloot L, Benoit-Cherifi M, Imbert-Bismut F, Sermet-Gaudelus I, Debray D. Comparison of Transient Elastography, ShearWave Elastography, Magnetic Resonance Elastography and FibroTest as routine diagnostic markers for assessing liver fibrosis in children with Cystic Fibrosis. Clin Res Hepatol Gastroenterol 2022; 46:101855. [PMID: 34933150 DOI: 10.1016/j.clinre.2021.101855] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/10/2021] [Accepted: 12/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Reliable markers are needed for early diagnosis and follow-up of liver disease in Cystic Fibrosis (CF). The objective was to evaluate the diagnostic performance of Transient Elastography (TE), Real-Time ShearWave Ultrasound Elastography (SWE), Magnetic Resonance Elastography (MRE) and the FibroTest as markers of Cystic Fibrosis Liver Disease (CFLD). METHODS A monocentric prospective cross-modality comparison study was proposed to all children (6 to 18 years of age) attending the CF center. Based on liver ultrasound findings, participants were classified into 3 groups: multinodular liver or portal hypertension (Nodular US/PH, advanced CFLD), heterogeneous increased echogenicity (Heterogeneous US, CFLD) or neither (Normal/Homogeneous US, no CFLD). The 4 tests were performed on the same day. The primary outcome was the FibroTest value and liver stiffness measurements (LSM). RESULTS 55 participants (mean age 12.6 ± 3.3 years; 25 girls) were included between 2015 and 2018: 23 in group Nodular US/PH, 8 in group Heterogeneous US and 24 in group Normal/Homogeneous US (including 4 with steatosis). LSM on TE, SWE and MRE were higher in participants with CFLD (groups Nodular US/PH and Heterogeneous US) compared to others (group Normal/Homogeneous US) (p<0.01), while FibroTest values did not differ (p = 0.09). The optimal cut-off values for predicting CFLD on TE, SWE and MRE were 8.7 (AUC=0.83, Se=0.71, Sp=0.96), 7.8 (AUC=0.85, Se=0.73, Sp=0.96) and 4.15 kPa (AUC=0.68, Se=0.73, Sp=0.64), respectively. LSM predicted the occurrence of major liver-related events at 3 years. TE and SWE were highly correlated (Spearman's ρ=0.9) and concordant in identifying advanced CFLD (Cohen's κ=0.84) while MRE was moderately correlated and concordant with TE (ρ=0.41; κ=36) and SWE (ρ=0.5; κ=0.50). CONCLUSION This study demonstrated excellent diagnostic performance of TE, SWE and MRE for the diagnosis of CFLD.
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Affiliation(s)
- Jérémy Dana
- Department of Pediatric Radiology, Hôpital Necker-Enfants Malades, AP-HP, Paris, France; IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France; Institut National de la Santé et de la Recherche Médicale (Inserm), U1110, Institut de Recherche sur les Maladies Virales et Hépatiques, Strasbourg, France.
| | - Muriel Girard
- 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; Inserm U1151, Institut Necker-Enfants Malades, Paris, France
| | - Stéphanie Franchi-Abella
- Department of Pediatric Radiology, APHP-Bicêtre Hospital, UMR BioMaps Paris-Saclay, Paris Saclay University, Kremlin-Bicêtre, France
| | - Laureline Berteloot
- Department of Pediatric Radiology, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | | | - Françoise Imbert-Bismut
- Department of Metabolic Biochemistry, Hôpital Pitié Salpétrière Charlefoix, AP-HP, Paris, France; Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Isabelle Sermet-Gaudelus
- Centre de Référence Maladies Rares (CRMR), Mucoviscidose et maladies de CFTR, European Respiratory Network Lung, Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, Paris, France; Inserm U1121, Necker-Enfants Malades Institute, Paris, France
| | - Dominique 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
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12
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Cystic fibrosis-related liver disease: Clinical presentations, diagnostic and monitoring approaches in the era of CFTR modulator therapies. J Hepatol 2022; 76:420-434. [PMID: 34678405 DOI: 10.1016/j.jhep.2021.09.042] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/09/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022]
Abstract
Cystic fibrosis (CF) is the most common autosomal recessive disease in the Caucasian population. Cystic fibrosis-related liver disease (CFLD) is defined as the pathogenesis related to the underlying CFTR defect in biliary epithelial cells. CFLD needs to be distinguished from other liver manifestations that may not have any pathological significance. The clinical/histological presentation and severity of CFLD vary. The main histological presentation of CFLD is focal biliary fibrosis, which is usually asymptomatic. Portal hypertension develops in a minority of cases (about 10%) and may require specific management including liver transplantation for end-stage liver disease. Portal hypertension is usually the result of the progression of focal biliary fibrosis to multilobular cirrhosis during childhood. Nevertheless, non-cirrhotic portal hypertension as a result of porto-sinusoidal vascular disease is now identified increasingly more frequently, mainly in young adults. To evaluate the effect of new CFTR modulator therapies on the liver, the spectrum of hepatobiliary involvement must first be precisely classified. This paper discusses the phenotypic features of CFLD, its underlying physiopathology and relevant diagnostic and follow-up approaches, with a special focus on imaging.
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13
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Magnetic resonance imaging of cystic fibrosis: Multi-organ imaging in the age of CFTR modulator therapies. J Cyst Fibros 2021; 21:e148-e157. [PMID: 34879996 DOI: 10.1016/j.jcf.2021.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 12/18/2022]
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14
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Ye W, Leung DH, Molleston JP, Ling SC, Murray KF, Nicholas JL, Huang S, Karmazyn BW, Harned RK, Masand P, Alazraki AL, Navarro OM, Otto RK, Palermo JJ, Towbin AJ, Alonso EM, Karnsakul WW, Jane Schwarzenberg S, Seidel GF, Siegel M, Magee JC, Narkewicz MR, Jay Freeman A. Association Between Transient Elastography and Controlled Attenuated Parameter and Liver Ultrasound in Children With Cystic Fibrosis. Hepatol Commun 2021; 5:1362-1372. [PMID: 34430781 PMCID: PMC8369935 DOI: 10.1002/hep4.1719] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/14/2021] [Accepted: 03/01/2021] [Indexed: 02/04/2023] Open
Abstract
Methods to identify children with cystic fibrosis (CF) at risk for development of advanced liver disease are lacking. We aim to determine the association between liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE) with research ultrasound (US) patterns and conventional hepatic markers as a potential means to follow liver disease progression in children with CF. ELASTIC (Longitudinal Assessment of Transient Elastography in CF) is a nested cohort of 141 patients, ages 7-21, enrolled in the Prediction by US of Risk of Hepatic Cirrhosis in CF (PUSH) Study. We studied the association between LSM with research-grade US patterns (normal [NL], heterogeneous [HTG], homogeneous [HMG], or nodular [NOD]) and conventional hepatic markers. In a subgroup (n = 79), the association between controlled attenuation parameter (CAP) and US pattern was explored. Among 133 subjects undergoing VCTE, NOD participants (n = 26) had a significantly higher median (interquartile range) LSM of 9.1 kPa (6.3, 15.8) versus NL (n = 72, 5.1 kPa [4.2, 7.0]; P < 0.0001), HMG (n = 17, 5.9 kPa [5.2, 7.8]; P = 0.0013), and HTG (n = 18, 6.1 kPa [4.7, 7.0]; P = 0.0008) participants. HMG participants (n = 14) had a significantly higher mean CAP (SD) (270.5 dB/m [61.1]) compared with NL (n = 40, 218.8 dB/m [46.5]; P = 0.0027), HTG (n = 10, 218.1 dB/m [60.7]; P = 0.044), and NOD (n = 15, 222.7 dB/m [56.4]; P = 0.041) participants. LSM had a negative correlation with platelet count (rs = - 0.28, P = 0.0071) and positive correlation with aspartate aminotransferase-to-platelet ratio index (rs = 0.38, P = 0.0002), Fibrosis-4 index (rs = 0.36, P = 0.0007), gamma-glutamyltransferase (GGT; rs = 0.35, P = 0.0017), GGT-to-platelet ratio (rs = 0.35, P = 0.003), and US spleen size z-score (rs = 0.27, P = 0.0073). Conclusion: VCTE is associated with US patterns and conventional markers in patients with liver disease with CF.
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Affiliation(s)
- Wen Ye
- Department of BiostatisticsUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and NutritionDepartment of PediatricsTexas Children's HospitalBaylor College of MedicineHoustonTXUSA
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology and NutritionRiley Hospital for Children at IU HealthIndiana University School of MedicineIndianapolisINUSA
| | - Simon C Ling
- The Hospital for Sick ChildrenDepartment of PediatricsUniversity of TorontoTorontoONCanada
| | - Karen F Murray
- Division of Gastroenterology and HepatologyUniversity of Washington and Seattle Children's HospitalSeattleWAUSA
| | - Jennifer L Nicholas
- Mallinckrodt Institute of RadiologyWashington University School of MedicineSt. LouisMOUSA
| | - Suiyuan Huang
- Department of BiostatisticsUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | - Boaz W Karmazyn
- Pediatric RadiologyRiley Hospital for Children at IU HealthIndiana University School of MedicineIndianapolisINUSA
| | - Roger K Harned
- Division of Pediatric RadiologyChildren's Hospital Colorado and University of Colorado School of MedicineAuroraCOUSA
| | - Prakash Masand
- Division of RadiologyTexas Children's HospitalHoustonTXUSA
| | - Adina L Alazraki
- Department of RadiologyEmory University School of Medicine and Children's Healthcare of AtlantaAtlantaGAUSA
| | - Oscar M Navarro
- Department of Medical ImagingUniversity of TorontoTorontoONCanada.,Department of Diagnostic ImagingThe Hospital for Sick ChildrenTorontoONCanada
| | - Randolph K Otto
- Department of RadiologyUniversity of Washington and Seattle Children's HospitalSeattleWAUSA
| | - Joseph J Palermo
- Division of Pediatric Gastroenterology, Hepatology and NutritionCincinnati Children's Hospital Medical CenterCincinnatiOHUSA.,Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Alexander J Towbin
- Department of RadiologyCincinnati Children's Hospital Medical CenterCincinnatiOHUSA.,Department of RadiologyUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Estella M Alonso
- Division of Pediatric Gastroenterology, Hepatology and NutritionAnn & Robert H. Lurie Children's HospitalChicagoILUSA
| | - Wikrom W Karnsakul
- Division of Pediatric Gastroenterology, Hepatology and NutritionJohn Hopkins School of MedicineBaltimoreMDUSA
| | | | - Glenn F Seidel
- Pediatric RadiologyLucile Packard Children's HospitalPalo AltoCAUSA
| | - Marilyn Siegel
- Mallinckrodt Institute of RadiologyWashington University School of MedicineSt. LouisMOUSA
| | - John C Magee
- Department of SurgeryUniversity of Michigan Medical SchoolAnn ArborMIUSA
| | - Michael R Narkewicz
- Digestive Health InstituteChildren's Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and NutritionDepartment of PediatricsUniversity of Colorado School of MedicineAuroraCOUSA
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and NutritionEmory University School of Medicine/Children's Healthcare of AtlantaAtlantaGAUSA
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15
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Ferraioli G, Barr RG, Dillman JR. Elastography for Pediatric Chronic Liver Disease: A Review and Expert Opinion. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:909-928. [PMID: 32881048 DOI: 10.1002/jum.15482] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/28/2020] [Accepted: 08/02/2020] [Indexed: 06/11/2023]
Abstract
In adults with chronic liver diseases, ultrasound and magnetic resonance shear wave elastography (SWE) can replace liver biopsy in several clinical scenarios. Several guidelines on the use of ultrasound SWE for the adult population have been published. However, the number of publications in the pediatric population is limited, and available guidelines on SWE do not specifically address pediatric chronic liver diseases. In this article, we review the literature on the use of SWE for pediatric chronic liver diseases and provide expert opinion on how to use SWE, both ultrasound and magnetic resonance techniques, in the pediatric population.
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Affiliation(s)
- Giovanna Ferraioli
- Ultrasound Unit, Department of Clinical Sciences and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | | | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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16
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Sağlam D, Demirbaş F, Bilgici MC, Yücel S, Çaltepe G, Eren E. Can Point Shear Wave Elastography Be Used as an Early Indicator of Involvement?: Evaluation of the Pancreas and Liver in Children With Cystic Fibrosis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1769-1776. [PMID: 32309883 DOI: 10.1002/jum.15281] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/28/2020] [Accepted: 03/05/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The aim of this study was to determine the effect of cystic fibrosis (CF) on pancreas and liver elasticity in young children using point shear wave elastography and to determine the relationship with clinical findings. METHODS Twenty-two patients with genetically proven CF, who were admitted to our pediatric gastroenterology clinic, and 22 healthy control participants were enrolled in the study. The shear wave velocity (SWV) of the liver and pancreas were measured with point shear wave elastography. RESULTS The 22 patients with CF included 45.5% girls with a mean age ± SD of 35 ± 35.8 months (range, 5-123 months). The 22 healthy control participants included 41.2% girls with a mean age of 58.9 ± 44.4 months (range, 2-159 months). The mean SWV of the pancreas in the patients with CF (1.06 ± 0.26 m/s) was significantly higher than that of the healthy control participants (0.85 ± 0.23 m/s; P = .01). The mean SWV of the liver in the patients with CF (1.46 ± 0.24 m/s) was significantly higher than that of the healthy control participants (1.12 ± 0.21 m/s; P = .001). The SWV of the pancreas and liver did not show any significant differences depending on ursodeoxycholic acid use, malnutrition status, and the presence of the F508 deletion mutation. CONCLUSIONS This study showed an increased SWV of the pancreas in children with CF, contrary to the literature. We also found an increased liver SWV even in the absence of CF-related liver disease. Ultrasound elastography may be a useful method of evaluating early changes in the pancreas and liver before the obvious clinical, laboratory, and B-mode ultrasound signs of CF-related involvement.
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Affiliation(s)
- Dilek Sağlam
- Department of Pediatric Radiology, Malatya Education and Research Hospital, Yeşilyurt, Turkey
| | - Fatma Demirbaş
- Diyarbakır Education and Research Hospital, Diyarbakır, Turkey
| | - Meltem Ceyhan Bilgici
- Departments of Pediatric Radiology, Ondokuz Mayıs University, School of Medicine, Kurupelit, Turkey
| | | | - Gönül Çaltepe
- Pediatric Gastroenterology, Ondokuz Mayıs University, School of Medicine, Kurupelit, Turkey
| | - Esra Eren
- Kayseri Education and Research Hospital, Kayseri, Turkey
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17
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Calvopina DA, Noble C, Weis A, Hartel GF, Ramm LE, Balouch F, Fernandez-Rojo MA, Coleman MA, Lewindon PJ, Ramm GA. Supersonic shear-wave elastography and APRI for the detection and staging of liver disease in pediatric cystic fibrosis. J Cyst Fibros 2020; 19:449-454. [DOI: 10.1016/j.jcf.2019.06.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/28/2019] [Accepted: 06/30/2019] [Indexed: 12/18/2022]
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18
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Abstract
PURPOSE OF REVIEW Liver disease in cystic fibrosis (CF) usually develops before puberty, is often asymptomatic and slowly progressive. Multilobular cirrhosis develops in approximately 5-10% of patients by the age of 18, and is a significant contributor to the morbidity and mortality. No therapy, including ursodeoxycholic acid and cystic fibrosis transmembrane conductance regulator correctors or potentiators, has proven effective to prevent or halt the progression of liver disease towards cirrhosis and portal hypertension. This review provides the current knowledge in the epidemiology of CF liver disease and development of noninvasive tools to assess liver disease severity and progression overtime in order to optimize clinical management and therapeutic options. RECENT FINDINGS Liver disease not only develops during childhood but also later in the lifetime of patients with CF; the incidence of cirrhosis with portal hypertension increases progressively reaching 10% by age 30. Several noninvasive tools to measure liver stiffness as an indirect measure of fibrosis are being investigated, and show promising results for the assessment of early stages of liver fibrosis and disease progression. SUMMARY Identifying noninvasive biomarkers is fundamental to improving early diagnosis, monitoring disease evolution and measuring treatment effects. A prerequisite is the use of consistent definitions for CF- liver disease (LD) in clinical trials.
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19
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Assessment of Selected Parameters of Liver Fibrosis and Inflammation in Patients with Diagnosed Cystic Fibrosis. Mediators Inflamm 2020; 2020:5696185. [PMID: 32308556 PMCID: PMC7132586 DOI: 10.1155/2020/5696185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/23/2020] [Accepted: 03/14/2020] [Indexed: 11/17/2022] Open
Abstract
Changes in the liver and bile ducts observed in patients diagnosed with cystic fibrosis result from inflammatory processes as well as fibrosis, remodeling, apoptosis, and cholestasis. As a consequence, portal hypertension, cirrhosis, and hepatic failure may develop. So far, the complexity of these processes has not been elucidated. Study Objectives. The aim of the study was to evaluate the selected parameters of hepatitis and fibrosis (Fibrotest, Actitest, and APRI) in patients diagnosed with cystic fibrosis. Material and Methods. The study included 79 patients with cystic fibrosis, aged 1 to 20 years (mean age 9.8 years), 49 girls (62%) and 30 boys (38%). The analysis involved the following: age, sex, clinical manifestations, laboratory tests evaluating pancreas function, parameters of liver damage, and cholestasis. Fibrotest, Actitest, and APRI were performed in all subjects. Results. Elevated parameters of hepatic cell damage (hypertransaminasemia) were found in 31/79 (39.2%) patients, while abnormal cholestasis parameters in 21/79 (26.6%). The abnormal results of Fibrotest were reported in 15% of patients (12/79), while of Actitest in 10% (8/79). In contrast, elevated APRI values were found in only 7.6% (6/79) of subjects. There was a statistically significant correlation between APRI and age (higher values were observed in younger children) and between Fibrotest and Actitest and pancreatic insufficiency (higher values were found in subjects without this abnormality). Moreover, Fibrotest values were significantly higher in girls. There was no correlation between Fibrotest, Actitest, and APRI values and the type of mutation. Conclusion. It appears that Fibrotest may be used as an early marker of liver fibrosis in patients with cystic fibrosis. Increased APRI values were only found in subjects with advanced hepatic lesions, most often in the form of portal hypertension.
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20
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Abstract
Cystic fibrosis (CF) is a multisystem disease caused by mutations in the CF transmembrane conductance regulator (CFTR) gene. CFTR is expressed in the apical surface of cholangiocytes. Homozygous CFTR gene mutation results in viscous and acidic bile secretions secondary to deficient surface fluid and bicarbonate efflux. Viscous, inspissated bile causes ductular obstruction and hepatotoxicity from retained bile components, leading to fibrosis and ultimately cirrhosis, known as CF liver disease (CFLD). CFLD is the third leading cause of death in CF patients. CFLD manifestations can take many forms. They range from asymptomatic elevation of transaminases to cirrhosis and end-stage liver disease. CFLD is diagnosed after excluding other causes of chronic liver disease. To date, there is no effective therapy to prevent or treat CFLD. Management of CFLD emphasizes on optimizing nutritional status. Ursodeoxycholic acid is the only available treatment that may prevent progression of CFLD at present. All CF patients with CFLD need annual investigations and follow-up for early detection of the disease. Liver transplantation should be considered in patients with decompensated cirrhosis and portal hypertension, with acceptable long-term outcomes. Novel therapies of CFLD are promising. This review article aims to summarize the published literature on CFLD, its pathophysiology, clinical features and complications, and management including new therapeutic options.
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Affiliation(s)
- Siham Al Sinani
- Graduate Medical Education Department, Oman Medical Specialty Board, Muscat, Oman.,Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman
| | - Sharef Al-Mulaabed
- Department of Pediatrics, Brookdale University Hospital Medical Center, Brooklyn, NY, USA
| | | | - Rabab Sultan
- Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman
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21
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Lewindon PJ, Puertolas-Lopez MV, Ramm LE, Noble C, Pereira TN, Wixey JA, Hartel GF, Calvopina DA, Leung DH, Ramm GA. Accuracy of Transient Elastography Data Combined With APRI in Detection and Staging of Liver Disease in Pediatric Patients With Cystic Fibrosis. Clin Gastroenterol Hepatol 2019; 17:2561-2569.e5. [PMID: 30880274 DOI: 10.1016/j.cgh.2019.03.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 02/24/2019] [Accepted: 03/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Liver disease develops in 15%-72% of patients with cystic fibrosis, and 5%-10% develop cirrhosis or portal hypertension, usually during childhood. Transient elastography (TE) is a noninvasive method to measure liver stiffness. We aimed to validate its accuracy in detection of liver disease and assessment of fibrosis in children with cystic fibrosis. METHODS We performed a cross-sectional study to evaluate the accuracy of TE in analysis of liver disease in 160 consecutive children who presented with cystic fibrosis (9.0 ± 0.4 years old, 53% male) at a tertiary referral pediatric center in Australia, from 2011 through 2016. Patients were classified as having cystic fibrosis-associated liver disease (CFLD) or cystic fibrosis without liver disease (CFnoLD) based on clinical, biochemical, and imaging features. Fibrosis severity was determined from histologic analysis of dual-pass liver biopsies from children with CFLD, as the reference standard. Data from healthy children without cystic fibrosis (n = 64, controls) were obtained from a separate study. Liver stiffness measurements (LSMs) were made by Fibroscan analysis, using the inter-quartile range/median ≤30% of 10 valid measurements. Children with macronodularity or portal hypertension with heterogeneous changes on ultrasound without available biopsy were assigned to the category of stage F3-F4 fibrosis. RESULTS LSM was made reliably in 86% of children; accuracy increased with age. LSMs were significantly higher in children with CFLD (10.7 ± 2.4 kPa, n = 33) than with CFnoLD (4.6 ± 0.1 kPa, n = 105) (P < .0001) or controls (4.1 ± 0.1kPa) (P < .0001); LSMs were higher in children with CFnoLD than controls (P < .05). At a cut-off value of 5.55kPa, LSM identified children with CFLD with an area under the receiver operating characteristic (AUROC) curve of 0.82, 70% sensitivity, and 82% specificity (P < .0001). Classification and regression tree models that combined LSM and aspartate aminotransferase to platelet ratio index (APRI) identified children with CFLD with an AUROC curve of 0.89, 87% sensitivity, and 74% specificity (odds ratio, 18.6). LSMs correlated with fibrosis stage in patients with CFLD (r = 0.67, P = .0001). A cut-off value of 8.7kPa differentiated patients with stage F3-F4 fibrosis from patients with stage F1-F2 fibrosis (AUROC, 0.87; 75% sensitivity; 100% specificity, P=.0002). The combination of LSMs and APRI improved the differentiation of patients with F3-F4 fibrosis vs F1-F2 fibrosis (AUROC, 0.92; 83% sensitivity; and 100% specificity (P < .01). CONCLUSIONS LSMs made by TE accurately detect liver disease in children with cystic fibrosis; diagnostic accuracy increases when LSMs are combined with APRI. LSMs also differentiate between children with cystic fibrosis with mild-moderate fibrosis vs advanced fibrosis.
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Affiliation(s)
- Peter J Lewindon
- Department of Gastroenterology, Hepatology and Liver Transplant, Lady Cilento Children's Hospital, Brisbane, Australia
| | - Mora V Puertolas-Lopez
- Holtz Children's Hospital, University of Miami/Jackson Memorial Medical Center, Miami, Florida
| | - Louise E Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Charlton Noble
- Department of Gastroenterology, Hepatology and Liver Transplant, Lady Cilento Children's Hospital, Brisbane, Australia
| | - Tamara N Pereira
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Julie A Wixey
- University of Queensland Centre for Clinical Research, Brisbane, Australia
| | - Gunter F Hartel
- Statistics Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Diego A Calvopina
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Daniel H Leung
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Division of Pediatric Gastroenterology, Hepatology, Nutrition, Texas Children's Hospital, Houston, Texas
| | - Grant A Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia.
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22
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Freeman AJ, Sellers ZM, Mazariegos G, Kelly A, Saiman L, Mallory G, Ling SC, Narkewicz MR, Leung DH. A Multidisciplinary Approach to Pretransplant and Posttransplant Management of Cystic Fibrosis-Associated Liver Disease. Liver Transpl 2019; 25:640-657. [PMID: 30697907 DOI: 10.1002/lt.25421] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 01/09/2019] [Indexed: 12/16/2022]
Abstract
Approximately 5%-10% of patients with cystic fibrosis (CF) will develop advanced liver disease with portal hypertension, representing the third leading cause of death among patients with CF. Cystic fibrosis with advanced liver disease and portal hypertension (CFLD) represents the most significant risk to patient mortality, second only to pulmonary or lung transplant complications in patients with CF. Currently, there is no medical therapy to treat or reverse CFLD. Liver transplantation (LT) in patients with CFLD with portal hypertension confers a significant survival advantage over those who do not receive LT, although the timing in which to optimize this benefit is unclear. Despite the value and efficacy of LT in selected patients with CFLD, established clinical criteria outlining indications and timing for LT as well as disease-specific transplant considerations are notably absent. The goal of this comprehensive and multidisciplinary report is to present recommendations on the unique CF-specific pre- and post-LT management issues clinicians should consider and will face.
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Affiliation(s)
- A Jay Freeman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Atlanta, GA
| | - Zachary M Sellers
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, Lucile Packard Children's Hospital at Stanford, Palo Alto, CA
| | - George Mazariegos
- Department of Surgery and Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Andrea Kelly
- Department of Pediatrics, Perelman School of Medicine of University of Pennsylvania, Philadelphia, PA.,Division of Pediatric Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Medical Center, New York, NY.,Division of Pediatric Infectious Diseases, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - George Mallory
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.,Divisions of Pediatric Pulmonary Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Simon C Ling
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, Toronto, Ontario, Canada
| | - Michael R Narkewicz
- Digestive Health Institute, Children's Hospital of Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Daniel H Leung
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.,Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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23
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Advances in diagnosis of chronic liver diseases in pediatric patients. World J Pediatr 2018; 14:541-547. [PMID: 30306466 DOI: 10.1007/s12519-018-0197-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 09/25/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Chronic liver diseases (CLD) present important clinical problem in children with various age-dependent causes. Nonalcoholic fatty liver disease (NAFLD) with its increasing prevalence is a major problem with regard to its timely recognition and the need for long-term disease monitoring. At present, a perfect non-invasive method for the evaluation of liver fibrosis is not available. METHODS A non-systematic literature search was performed to summarize the current knowledge about transient elastography (TE) with controlled attenuation parameter (CAP) in children with CLD. Ovid MEDLINE, Ovid EMBASE, Google scholar, and The Cochrane Library databases were searched for relevant articles evaluating TE in the pediatric population. RESULTS Normal values of liver stiffness measurements (LSM) according to the age are given, as well as the advantages and disadvantages of the method. The utility of TE in specific liver disease in pediatric population is summarized. CONCLUSIONS TE with CAP is a valuable non-invasive method for the liver-damage assessment. Clinical interpretation of TE results should be made in parallel with the assessment of the patient's demographics, disease etiology, and essential laboratory parameters.
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24
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Bolia R, Ooi CY, Lewindon P, Bishop J, Ranganathan S, Harrison J, Ford K, van der Haak N, Oliver MR. Practical approach to the gastrointestinal manifestations of cystic fibrosis. J Paediatr Child Health 2018; 54:609-619. [PMID: 29768684 DOI: 10.1111/jpc.13921] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/07/2018] [Accepted: 03/02/2018] [Indexed: 12/14/2022]
Abstract
Cystic fibrosis (CF) is the most common, life-shortening, genetic illness affecting children in Australia and New Zealand. The genetic abnormality results in abnormal anion transport across the apical membrane of epithelial cells in a number of organs, including the lungs, gastrointestinal tract, liver and genito-urinary tract. Thus, CF is a multi-system disorder that requires a multi-disciplinary approach. Respiratory disease is the predominant cause of both morbidity and mortality in patients with CF. However, there are significant and clinically relevant gastrointestinal, liver, pancreatic and nutritional manifestations that must be detected and managed in a timely and structured manner. The aim of this review is to provide evidence-based information and clinical algorithms to guide the nutritional and gastrointestinal management of patients with CF.
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Affiliation(s)
- Rishi Bolia
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Chee Y Ooi
- School of Women and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,miCF Research Centre and Department of Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Peter Lewindon
- Department of Gastroenterology, Lady Cilento Children's Hospital and Queensland Liver Transplant Service, Brisbane, Queensland, Australia
| | - Jonathan Bishop
- Department of Paediatric Gastroenterology, Starship Children's Hospital, Auckland, New Zealand
| | - Sarath Ranganathan
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Jo Harrison
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Kristyn Ford
- Department of Nutrition and Dietetics, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Natalie van der Haak
- Department of Nutrition and Dietetics, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Mark R Oliver
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, University of Melbourne, Melbourne, Victoria, Australia
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25
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Davison S. Assessment of liver disease in cystic fibrosis. Paediatr Respir Rev 2018; 27:24-27. [PMID: 29933897 DOI: 10.1016/j.prrv.2018.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/10/2018] [Indexed: 10/16/2022]
Abstract
Liver disease in cystic fibrosis has many causes, with biliary fibrosis due to abnormal CFTR protein predominating. Assessment requires aetiology to be defined. Biliary fibrosis may progress to cirrhosis and portal hypertension, which although initially asymptomatic, may cause varices and splenomegaly. Monitoring progression includes clinical and ultrasound assessment with endoscopic assessment of varices for those at risk. Extrapolated primarily from longitudinal assessment of viral hepatitis in adults, non-invasive elastography has a potential role. Evidence is lacking to support intervention strategies, but ursodeoxycholic acid and ligation of varices are widely applied. Indication and timing of liver transplantation are not clearly defined. Multidisciplinary approach is needed to tailor assessment and guide management.
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Affiliation(s)
- Suzanne Davison
- Paediatric Hepatologist, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, UK.
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26
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Abstract
PURPOSE OF REVIEW The aim of this study was to provide an overview of the current understanding of the pathophysiology, diagnosis and management of cystic fibrosis-liver disease (CFLD). RECENT FINDINGS CFLD has a variety of manifestations. Previously, it was thought that patients progressed from mild cholestatic disease to cirrhosis to decompensated cirrhosis with portal hypertension. Newer evidence suggests that some patients may develop cirrhosis while others develop noncirrhotic portal hypertension. Advances in our understanding of the pathophysiology of disease necessitate modifications to the current diagnostic criteria. Both fibroscan and noninvasive biomarkers can be used to identify patients with cirrhosis and portal hypertension. Ursodeoxycholic acid remains the mainstay of therapy despite a paucity of rigorous studies supporting its use. Novel therapeutic agents such as CF transmembrane conductance regulator (CFTR) modulators and potentiators are encouraging but need to be evaluated specifically in CFLD. SUMMARY A better understanding of the pathophysiology of disease is critical to developing more disease-specific diagnostics and therapeutics.
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