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Kurkal K, Kuek SL, Herath D, Ong C, Harrison J, Cooney H, Poulter C, Oliver M. Outcomes of a cross-sectional ultrasound- based study of cystic fibrosis related liver disease: A real world experience. J Cyst Fibros 2024; 23:1129-1133. [PMID: 38942721 DOI: 10.1016/j.jcf.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/28/2024] [Accepted: 06/11/2024] [Indexed: 06/30/2024]
Abstract
AIMS To study the prevalence of cystic fibrosis related liver disease (CFLD) as defined by ultrasound (US) and describe difference in clinical and radiological features in those with CFLD and those without CFLD (nCFLD); with and without portal hypertension (PHT and nPHT). METHODS Children with CF (CwCF) from our clinic who had regular screening liver US from 3 years of age were included. Liver parenchyma findings were classified into normal, homogeneous, heterogeneous and nodular. For our study, we defined PHT as US evidence of splenomegaly and/or ascites, abnormal portal flow, varices, ligamentum teres recanalization if present. Demographic, clinical, nutritional and lung function between the two groups-CFLD/nCFLD; and subgroups- PHT and nPHT were compared. Gamma glutamyl transferase (GGT)/ platelet ratio (GPR) as a marker of fibrosis was measured. RESULTS From 227 CwCF,40 (17 %) were excluded (below the age of 3 years or alternative cause of liver disease). Of the remaining 187, 107 (57 %) had a normal US, 80 (43 %) had CFLD; 25 (13.4 %) had PHT. There was no significant difference in demographics, BMI-z score, lung function, presence of gastrostomy or pancreatic insufficiency in CFLD vs nCFLD and PHT vs nPHT. CF related diabetes mellitus (CFRD) was significantly associated with CFLD vs nCFLD (P = 0.0086). GGT was higher and platelet count was lower in PHT vs nPHT (P = 0.0256 and P = 0.0001). Nodularity was strongly associated with an elevated GPR (P = 0.016). There was a strong association between nodularity on US and PHT (P = 0.0006). CONCLUSION Nodularity is a clear marker for advanced liver disease with higher scores for a non-invasive marker for fibrosis. There was no difference in nutrition and FEV1 between advanced liver disease and absent/ milder liver disease.
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Affiliation(s)
- Kavya Kurkal
- Department of Gastroenterology, Royal Children's Hospital, Parkville, Melbourne, Australia
| | - Stephanie L Kuek
- Department of Respiratory, Royal Children's Hospital, Parkville, Melbourne, Australia
| | - Dumindu Herath
- Department of Radiology, Royal Children's Hospital, Parkville, Melbourne, Australia
| | - Cyril Ong
- Department of Radiology, Royal Children's Hospital, Parkville, Melbourne, Australia
| | - Joanne Harrison
- Department of Respiratory, Royal Children's Hospital, Parkville, Melbourne, Australia; University of Melbourne, Parkville, Melbourne, Australia; Murdoch Children's Research Institute, Parkville, Melbourne, Australia
| | - Hannah Cooney
- Department of Respiratory, Royal Children's Hospital, Parkville, Melbourne, Australia
| | - Caroline Poulter
- Department of Gastroenterology, Royal Children's Hospital, Parkville, Melbourne, Australia
| | - Mark Oliver
- Department of Gastroenterology, Royal Children's Hospital, Parkville, Melbourne, Australia; University of Melbourne, Parkville, Melbourne, Australia.
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Ling H, Raraigh KS, Pugh EW, Aksit MA, Zhang P, Pace RG, Faino AV, Bamshad MJ, Gibson RL, O'Neal W, Knowles MR, Blackman SM, Cutting GR. Genetic modifiers of body mass index in individuals with cystic fibrosis. Am J Hum Genet 2024; 111:2203-2218. [PMID: 39260370 PMCID: PMC11480786 DOI: 10.1016/j.ajhg.2024.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 08/07/2024] [Accepted: 08/07/2024] [Indexed: 09/13/2024] Open
Abstract
To identify modifier loci underlying variation in body mass index (BMI) in persons with cystic fibrosis (pwCF), we performed a genome-wide association study (GWAS). Utilizing longitudinal height and weight data, along with demographic information and covariates from 4,393 pwCF, we calculated AvgBMIz representing the average of per-quarter BMI Z scores. The GWAS incorporated 9.8M single nucleotide polymorphisms (SNPs) with a minor allele frequency (MAF) > 0.005 extracted from whole-genome sequencing (WGS) of each study subject. We observed genome-wide significant association with a variant in FTO (FaT mass and Obesity-associated gene; rs28567725; p value = 1.21e-08; MAF = 0.41, β = 0.106; n = 4,393 individuals) and a variant within ADAMTS5 (A Disintegrin And Metalloproteinase with ThromboSpondin motifs 5; rs162500; p value = 2.11e-10; MAF = 0.005, β = -0.768; n = 4,085 pancreatic-insufficient individuals). Notably, BMI-associated variants in ADAMTS5 occur on a haplotype that is much more common in African (AFR, MAF = 0.183) than European (EUR, MAF = 0.006) populations (1000 Genomes project). A polygenic risk score (PRS) calculated using 924 SNPs (excluding 17 in FTO) showed significant association with AvgBMIz (p value = 2.2e-16; r2 = 0.03). Association between variants in FTO and the PRS correlation reveals similarities in the genetic architecture of BMI in CF and the general population. Inclusion of Black individuals in whom the single-gene disorder CF is much less common but genomic diversity is greater facilitated detection of association with variants that are in LD with functional SNPs in ADAMTS5. Our results illustrate the importance of population diversity, particularly when attempting to identify variants that manifest only under certain physiologic conditions.
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Affiliation(s)
- Hua Ling
- Center for Inherited Disease Research, Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Karen S Raraigh
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Elizabeth W Pugh
- Center for Inherited Disease Research, Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Melis A Aksit
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Peng Zhang
- Center for Inherited Disease Research, Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Rhonda G Pace
- Marsico Lung Institute/UNC CF Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Anna V Faino
- Children's Core for Biostatistics, Epidemiology and Analytics in Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Michael J Bamshad
- Brotman Baty Institute for Precision Medicine, Seattle, WA 98195, USA; Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle, WA 98195, USA; Department of Genome Sciences, University of Washington, Seattle, WA 98195, USA; Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, WA 98105, USA
| | - Ronald L Gibson
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, WA 98105, USA; Department of Pediatrics, Division of Pulmonary & Sleep Medicine, University of Washington School of Medicine/Seattle Children's Hospital, Seattle, WA, USA
| | - Wanda O'Neal
- Marsico Lung Institute/UNC CF Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Michael R Knowles
- Marsico Lung Institute/UNC CF Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Scott M Blackman
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; Division of Pediatric Endocrinology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Garry R Cutting
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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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: 0.5] [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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Issa Z, Gohy S, Zech F, Baldin P, Delire B, Dahlqvist G. Prevalence and characteristics of cystic fibrosis liver disease: a study highlighting the lack of histological diagnosis. Clin Res Hepatol Gastroenterol 2022; 46:101977. [PMID: 35772685 DOI: 10.1016/j.clinre.2022.101977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/24/2022] [Accepted: 06/08/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Cystic fibrosis liver disease (CFLD) is the third leading cause of death in patients with cystic fibrosis (CF). We aim to determine the prevalence of CFLD in a cohort of adult patients with CF and to characterise liver involvement in this population highlighting the importance of histological diagnosis. METHODS We retrospectively studied a cohort of patients with CF. Inclusion criteria were age ≥ 18 and minimum 1 year of follow-up. We excluded lung transplant patients. CFLD was defined as having 2 out of 3 criteria: persistent elevation of transaminases and/or gamma-glutamyltransferase; abnormal ultrasound; and abnormal transient elastography. Non-invasive fibrosis biomarkers were calculated in CFLD patients. Adult-onset CFLD (Ad-CFLD) was defined as CFLD ≥18 years. Severe CFLD (s-CFLD) was defined as CFLD with cirrhosis and/or portal hypertension. RESULTS We included 113 patients. Median age was 29 years, 58 were male. Forty patients had CFLD. Median age at CFLD diagnosis was 10 years. Twenty-one patients had s-CFLD. Two s-CFLD patients had nodular regenerative hyperplasia, 1 had hepatocellular carcinoma and 4 underwent liver transplantation. Six patients had ad-CFLD. Both CFLD and s-CFLD groups were compared to a non-CFLD group. The CFLD group had significantly more males (p = 0.034). S-CFLD group had worse pulmonary function (p = 0.015). CONCLUSION Thirty five percent of adult patients with CF, mainly males, had CFLD. Nineteen percent had s-CFLD and had worse pulmonary function. With recent reports unravelling different pathophysiological mechanisms in CFLD, we believe it is important to better characterise liver involvement using liver biopsy.
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Affiliation(s)
- Zaina Issa
- Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
| | - Sophie Gohy
- Department of Pneumology, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Cystic Fibrosis Reference Center, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Francis Zech
- Department of Infectious Diseases, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Pamela Baldin
- Department of Anatomopathology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Bénédicte Delire
- Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Géraldine Dahlqvist
- Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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5
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Aksit MA, Ling H, Pace RG, Raraigh KS, Onchiri F, Faino AV, Pagel K, Pugh E, Stilp AM, Sun Q, Blue EE, Wright FA, Zhou YH, Bamshad MJ, Gibson RL, Knowles MR, Cutting GR, Blackman SM. Pleiotropic modifiers of age-related diabetes and neonatal intestinal obstruction in cystic fibrosis. Am J Hum Genet 2022; 109:1894-1908. [PMID: 36206743 PMCID: PMC9606479 DOI: 10.1016/j.ajhg.2022.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 09/12/2022] [Indexed: 01/25/2023] Open
Abstract
Individuals with cystic fibrosis (CF) develop complications of the gastrointestinal tract influenced by genetic variants outside of CFTR. Cystic fibrosis-related diabetes (CFRD) is a distinct form of diabetes with a variable age of onset that occurs frequently in individuals with CF, while meconium ileus (MI) is a severe neonatal intestinal obstruction affecting ∼20% of newborns with CF. CFRD and MI are slightly correlated traits with previous evidence of overlap in their genetic architectures. To better understand the genetic commonality between CFRD and MI, we used whole-genome-sequencing data from the CF Genome Project to perform genome-wide association. These analyses revealed variants at 11 loci (6 not previously identified) that associated with MI and at 12 loci (5 not previously identified) that associated with CFRD. Of these, variants at SLC26A9, CEBPB, and PRSS1 associated with both traits; variants at SLC26A9 and CEBPB increased risk for both traits, while variants at PRSS1, the higher-risk alleles for CFRD, conferred lower risk for MI. Furthermore, common and rare variants within the SLC26A9 locus associated with MI only or CFRD only. As expected, different loci modify risk of CFRD and MI; however, a subset exhibit pleiotropic effects indicating etiologic and mechanistic overlap between these two otherwise distinct complications of CF.
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Affiliation(s)
- Melis A Aksit
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Hua Ling
- Department of Genetic Medicine, Center for Inherited Disease Research, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Rhonda G Pace
- Marsico Lung Institute/UNC CF Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Karen S Raraigh
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Frankline Onchiri
- Children's Core for Biostatistics, Epidemiology and Analytics in Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Anna V Faino
- Children's Core for Biostatistics, Epidemiology and Analytics in Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Kymberleigh Pagel
- The Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD 21218, USA
| | - Elizabeth Pugh
- Department of Genetic Medicine, Center for Inherited Disease Research, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Adrienne M Stilp
- Department of Biostatistics, University of Washington, Seattle, WA 98195, USA
| | - Quan Sun
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Elizabeth E Blue
- Department of Medicine, Division of Medical Genetics, University of Washington, Seattle, WA 98195, USA; Brotman Baty Institute for Precision Medicine, Seattle, WA 98195, USA
| | - Fred A Wright
- Department of Statistics, North Carolina State University, Raleigh, NC 27797, USA; Bioinformatics Research Center, North Carolina State University, Raleigh, NC 27797, USA; Department of Biological Sciences, North Carolina State University, Raleigh, NC 27797, USA
| | - Yi-Hui Zhou
- Bioinformatics Research Center, North Carolina State University, Raleigh, NC 27797, USA
| | - Michael J Bamshad
- Brotman Baty Institute for Precision Medicine, Seattle, WA 98195, USA; Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle, WA 98195, USA; Department of Genome Sciences, University of Washington, Seattle, WA 98195, USA; Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, WA 98105, USA
| | - Ronald L Gibson
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, WA 98105, USA; Department of Pediatrics, Division of Pulmonary & Sleep Medicine, University of Washington School of Medicine/Seattle Children's Hospital, Seattle, WA, USA
| | - Michael R Knowles
- Marsico Lung Institute/UNC CF Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Garry R Cutting
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Scott M Blackman
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Division of Pediatric Endocrinology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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6
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Leung DH, Ye W, Schwarzenberg SJ, Freeman AJ, Palermo JJ, Weymann A, Alonso EM, Karnsakul WW, Murray KF, Stoll JM, Huang S, Karmazyn B, Masand P, Magee JC, Alazraki AL, Towbin AJ, Nicholas JL, Green N, Otto RK, Siegel MJ, Ling SC, Navarro OM, Harned RK, Narkewicz MR, Molleston JP. Long-term follow-up and liver outcomes in children with cystic fibrosis and nodular liver on ultrasound in a multi-center study. J Cyst Fibros 2022; 22:248-255. [PMID: 35985930 DOI: 10.1016/j.jcf.2022.07.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/30/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Nodular liver (NOD) in cystic fibrosis (CF) suggests advanced CF liver disease (aCFLD); little is known about progression of liver disease (LD) after detection of sonographic NOD. METHODS Clinical, laboratory, and ultrasound (US) data from Prediction by Ultrasound of the Risk of Hepatic Cirrhosis in CFLD Study participants with NOD at screening or follow-up were compared with normal (NL). Linear mixed effects models were used for risk factors for LD progression and Kaplan-Meier estimator for time-to-event. RESULTS 54 children with NOD (22 screening, 32 follow-up) and 112 NL were evaluated. Baseline (BL) and trajectory of forced expiratory volume, forced vital capacity, height/BMI z-scores were similar in NOD vs NL. Platelets were lower in NOD at BL (250 vs 331×103/microL; p < 0.001) and decreased by 8600/year vs 2500 in NL. Mean AST to Platelet Ratio Index (1.1 vs 0.4; p < 0.001), Fibrosis-4 Index (0.4 vs 0.2, p < 0.001), and spleen size z-score (SSZ) [1.5 vs 0.02; p < 0.001] were higher in NOD at BL; SSZ increased by 0.5 unit/year in NOD vs 0.1 unit/year in NL. Median liver stiffness (LSM) by transient elastography was higher in NOD (8.2 kPa, IQR 6-11.8) vs NL (5.3, 4.2-7, p < 0.0001). Over 6.3 years follow-up (1.3-10.3), 6 NOD had esophageal varices (cumulative incidence in 10 years: 20%; 95% CI: 0.0%, 40.0%), 2 had variceal bleeding, and 2 underwent liver transplantation; none had ascites or hepatic encephalopathy. No NL experienced liver-related events. CONCLUSIONS NOD developed clinically evident portal hypertension faster than NL without worse growth or lung disease.
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Key Words
- ALT, alanine aminotransferase
- APRI, aspartate aminotransferase to platelet ratio index
- AST, aminotransferase
- CAP, continuous attenuation parameter
- CFRD, cystic-fibrosis-related diabetes
- CFTR, cystic fibrosis transmembrane regulator
- Cirrhosis
- Cystic fibrosis liver disease
- FEV1, forced expiratory volume in one second
- FIB4, fibrosis index based on four factors
- FVC, forced vital capacity
- GGT, gamma-glutamyl transferase
- IGT, impaired glucose tolerance
- INR, international normalized ratio
- LSM, liver stiffness measurement
- NL, normal
- NOD, nodular
- PELD, pediatric end-stage liver disease
- PUSH, prediction by ultrasound of the risk of hepatic cirrhosis
- US, ultrasound
- Ultrasound
- VCTE, vibration controlled transient elastography
- WBC, white blood cell count
- abbreviations: CF, cystic fibrosis
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Affiliation(s)
- Daniel H Leung
- Department of Pediatrics, Baylor College of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, 6621 Fannin St, CCC 1010.00, Houston, TX 77030, USA
| | - Wen Ye
- Department of Biostatistics, University of Michigan, 1420 Washington Heights, M4073 SPH II, Ann Arbor, MI 48109, USA
| | - Sarah J Schwarzenberg
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Minnesota, 2450 Riverside Save S AO-201, Minneapolis, MN 55454, USA
| | - A Jay Freeman
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University, 2015 Uppergate Drive, NE, Atlanta, GA 30322, USA
| | - Joseph J Palermo
- Department of Pediatrics, Division of Gastroenterology, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 2010, Cincinnati, OH 45229, USA
| | - Alexander Weymann
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA
| | - Estella M Alonso
- Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Northwestern University Feinberg School of Medicine, 225 E. Chicago Avenue, Box 57, Chicago, IL 60611, USA
| | - Wikrom W Karnsakul
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, 600 N Wolfe Street, CMSC-2, Baltimore, MD 21287, USA
| | - Karen F Murray
- Pediatric Institute and Cleveland Clinic Children's, Cleveland Clinic, 8950 Euclid Avenue, R3, Cleveland, OH 44195, USA
| | - Janis M Stoll
- Department of Pediatrics, Division of Gastroenterology, Pediatric Hepatology and Nutrition, Washington University School of Medicine in St. Louis, One Children's Place, Suite 8116, St. Louis, MO 63110, USA
| | - Suiyuan Huang
- Department of Biostatistics, University of Michigan, 1420 Washington Heights, M4073 SPH II, Ann Arbor, MI 48109, USA
| | - Boaz Karmazyn
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N. University Blvd, Rm 0663, Indianapolis, IN 46202, USA
| | - Prakash Masand
- Department of Pediatrics, Baylor College of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, 6621 Fannin St, CCC 1010.00, Houston, TX 77030, USA
| | - John C Magee
- Department of Surgery, University of Michigan School of Medicine, 1500 E Medical Center Drive, UH South Rm 6689, Ann Arbor, MI 48109, USA
| | - Adina L Alazraki
- Department of Radiology, Children's Healthcare of Atlanta, Emory University, 1405 Clifton Rd NE, Atlanta, GA 30322, USA
| | - Alexander J Towbin
- Department of Radiology, University of Cincinnati College of Medicine, 234 Goodman Street, PO Box 670761, Cincinnati, OH 45267, USA
| | - Jennifer L Nicholas
- Department of Radiology, Division of Pediatric Imaging, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Nicole Green
- Department of Pediatrics, Division of Gastroenterology and Hepatology, Seattle Children's Hospital, 4800 Sand Point Way NE, PO Box 5371, Seattle, WA 98105, USA
| | - Randolph K Otto
- Department of Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, MA.7.220, Seattle, WA 98105, USA
| | - Marilyn J Siegel
- Edward Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Blvd, St. Louis, MO 63110, USA
| | - Simon C Ling
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, University of Toronto, 555 University Ave ON, Toronto, M5G 1X8, Canada
| | - Oscar M Navarro
- Department of Diagnostic Imaging, Division of Pediatric Imaging, University of Toronto, 263 McCaul St 4th floor, Toronto, ON M5T 1W7, Canada
| | - Roger K Harned
- Department of Radiology-Diagnostics, University of Colorado School of Medicine, 13123 East 16th Avenue, B125, Aurora, CO 80045, 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 Medicine, 13123 East 16th Avenue, B290, Aurora, CO 80045, USA
| | - Jean P Molleston
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children at IU Health, Indiana University School of Medicine, 705 Riley Hospital Drive, ROC 4210, Indianapolis, IN 46202, USA.
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H E, CR H, S D, EA E. 2D Shear Wave Elastography, a promising screening tool for Cystic Fibrosis liver disease, shows a correlation between vitamin D and liver stiffness. J Cyst Fibros 2022; 21:873-877. [DOI: 10.1016/j.jcf.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 05/24/2022] [Accepted: 06/17/2022] [Indexed: 11/25/2022]
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Shteinberg M, Haq IJ, Polineni D, Davies JC. Cystic fibrosis. Lancet 2021; 397:2195-2211. [PMID: 34090606 DOI: 10.1016/s0140-6736(20)32542-3] [Citation(s) in RCA: 353] [Impact Index Per Article: 88.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/03/2020] [Accepted: 11/20/2020] [Indexed: 12/11/2022]
Abstract
Cystic fibrosis is a monogenic disease considered to affect at least 100 000 people worldwide. Mutations in CFTR, the gene encoding the epithelial ion channel that normally transports chloride and bicarbonate, lead to impaired mucus hydration and clearance. Classical cystic fibrosis is thus characterised by chronic pulmonary infection and inflammation, pancreatic exocrine insufficiency, male infertility, and might include several comorbidities such as cystic fibrosis-related diabetes or cystic fibrosis liver disease. This autosomal recessive disease is diagnosed in many regions following newborn screening, whereas in other regions, diagnosis is based on a group of recognised multiorgan clinical manifestations, raised sweat chloride concentrations, or CFTR mutations. Disease that is less easily diagnosed, and in some cases affecting only one organ, can be seen in the context of gene variants leading to residual protein function. Management strategies, including augmenting mucociliary clearance and aggressively treating infections, have gradually improved life expectancy for people with cystic fibrosis. However, restoration of CFTR function via new small molecule modulator drugs is transforming the disease for many patients. Clinical trial pipelines are actively exploring many other approaches, which will be increasingly needed as survival improves and as the population of adults with cystic fibrosis increases. Here, we present the current understanding of CFTR mutations, protein function, and disease pathophysiology, consider strengths and limitations of current management strategies, and look to the future of multidisciplinary care for those with cystic fibrosis.
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Affiliation(s)
- Michal Shteinberg
- Pulmonology Institute and CF Center, Carmel Medical Center, Haifa, Israel; Rappaport Faculty of Medicine, The Technion-Israel Institute of Technology, Haifa, Israel
| | - Iram J Haq
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Jane C Davies
- National Heart and Lung Institute, Imperial College London, London, UK; Royal Brompton and Harefield, Guy's and St Thomas' NHS Foundation Trust, London, UK.
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Woolfson JP, Schreiber RA, Raveendran S, Chilvers M, Barker C, Guttman OR. Role of transient elastography and APRI in the assessment of pediatric cystic fibrosis liver disease. CANADIAN LIVER JOURNAL 2021; 4:23-32. [PMID: 35991474 PMCID: PMC9203161 DOI: 10.3138/canlivj-2020-0008] [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: 04/16/2020] [Accepted: 07/05/2020] [Indexed: 08/31/2024]
Abstract
Background Diagnosis and monitoring of cystic fibrosis liver disease (CFLD) is challenging. Transient elastography (TE) is a rapid, non-invasive method for assessing liver fibrosis. Its role in detecting fibrosis in CFLD has only begun to be explored. The aspartate aminotransferase to platelet ratio index (APRI) has been validated as a predictor of hepatic fibrosis in other chronic liver diseases. The purpose of this study was to assess the utility of APRI and TE in identifying liver fibrosis in pediatric CF patients. Methods Patients aged 2-18 years were recruited from the British Columbia Children's Hospital CF clinic. Patients were determined to have CFLD using standard criteria. Charts were reviewed, and each patient underwent TE. Results Of the 55 patients included in the study (50.9% male, mean age 11.6 y), 22 (40%) had CFLD. All mean liver enzymes were higher in the CFLD group, notably alanine transaminase (p = 0.031). Mean liver stiffness (LS) and APRI were also higher in the CFLD group (LS: 5.9 versus 4.5 kPa, p = 0.015; APRI: 0.40 versus 0.32, p = 0.119). Linear regression showed a mild positive association between the two (r 2 = 0.386). Conclusions TE values were higher among CFLD patients and correlated with APRI values, suggesting that these tools may have clinical applications for identifying and following this population. Further research is needed on a larger scale to determine the relative value and clinical utility of TE and APRI among patients with CFLD.
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Affiliation(s)
- Jessica P Woolfson
- Division of Gastroenterology, Hepatology and Nutrition, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard A Schreiber
- Division of Gastroenterology, Hepatology and Nutrition, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Mark Chilvers
- University of British Columbia, Vancouver, British Columbia, Canada
- Division of Respiratory Medicine, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Collin Barker
- Division of Gastroenterology, Hepatology and Nutrition, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Orlee R Guttman
- Division of Gastroenterology, Hepatology and Nutrition, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
- University of British Columbia, Vancouver, British Columbia, Canada
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Cystic Fibrosis-related Liver Disease is Associated With Increased Disease Burden and Endocrine Comorbidities. J Pediatr Gastroenterol Nutr 2020; 70:796-800. [PMID: 32443033 DOI: 10.1097/mpg.0000000000002694] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cystic fibrosis-related liver disease (CFLD) is the leading nonpulmonary cause of mortality in cystic fibrosis (CF). We evaluated and compared the burden of disease and nonrespiratory comorbidities of those with severe CFLD and those without (noCFLD). METHODS A retrospective nationwide (Australia) longitudinal review (from 1998 to 2016) of severe CFLD patients compared with noCFLD controls (matched 1 : 1 for age, genotype, pancreatic insufficiency, and center). RESULTS One hundred sixty-six patients with severe CFLD and 166 with noCFLD were identified. Forced expiratory volume in 1 second percentage of predicted (FEV1%) was significantly lower in CFLD than noCFLD across all ages (estimate [SE] -6.05% [2.12]; P = 0.004). Median (IQR) hospitalizations per patient per year were higher in CFLD than noCFLD for: respiratory indications (0.6 [0.2-1.3] vs 0.4 [0.1-0.9]; P = 0.002); gastrointestinal indications (0.09 [0-0.2] vs 0 [0-0.05]; P < 0.001); and other indications (0.05 [0-0.2] vs 0 [0-0.1]; P = 0.03). In the CFLD cohort, there was increased use of nasogastric (12.6% vs 5.4%; OR 2.51 [95% CI 1.06-6.46]; P = 0.03) and gastrostomy nutritional supplementation (22.9% vs 13.2%; OR 1.93 [95% CI 1.05-3.63]; P = 0.03). Additionally, the CFLD cohort had a higher frequency of bone diseases, osteopenia (26.5% vs 16.8%; OR 1.77 [95%CI 1.01-3.15]; P = 0.04) and osteoporosis (16.2% vs 8.4%; OR 2.1 [95% CI 1.01-4.52]; P = 0.04), as well as CF-related diabetes (38.5% vs 19.2%; OR 2.61 [95% CI 1.55-4.47]; P = 0.001). CONCLUSIONS Patients with severe CFLD have greater disease burden, with higher number of hospitalizations (both respiratory and nonrespiratory indications), nutritional interventions, and are at higher risk of CF-related bone disease and diabetes.
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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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Hepatobiliary Involvement in Cystic Fibrosis. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Strong toll-like receptor responses in cystic fibrosis patients are associated with higher lung function. J Cyst Fibros 2019; 19:608-613. [PMID: 31813753 DOI: 10.1016/j.jcf.2019.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) airways disease varies widely among patients with identical cystic fibrosis transmembrane conductance regulator (CFTR) genotypes. Robust airway inflammation is thought to be deleterious in CF; inter-individual variation in Toll-like receptor (TLR)-mediated innate immune inflammatory responses (TMIIR) might account for a portion of the phenotypic variation. We tested if TMIIR in people with CF are different than those of healthy controls, and whether higher TMIIR in people with CF are associated with reduced lung function. METHODS We cultured whole blood from clinically stable subjects with CF (n = 76) and healthy controls (n = 45) with TLR agonists, and measured cytokine production and expression of TLR-associated genes. We tested for differences in TLR-stimulated cytokine levels between subjects with CF and healthy subjects, and for associations between cytokine and gene expression levels with baseline lung function (forced expiratory volume in one second percent predicted (FEV1%)) and decline in FEV1% over time. RESULTS TMIIR in blood from subjects with CF were lower than in healthy controls. Expression of TLR regulators SARM1, TOLLIP, and AKT1 were downregulated in CF. In subjects with CF we found that lower TLR4-agonist-induced IL-8 was associated with lower FEV1% at enrollment (p<0.001) and with greater five year FEV1% decline (p<0.001). CONCLUSIONS TMIIR were lower in people with CF relative to healthy controls; however, unexpectedly, greater whole blood TMIIR were positively associated with lung function in people with CF. These findings suggest a complex interaction between inflammation and disease in people with CF.
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Elborn JS, Gonska T. Using registries for research in CF. How can we be sure about the outputs? J Cyst Fibros 2019; 18:309-310. [PMID: 30982754 DOI: 10.1016/j.jcf.2019.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- J Stuart Elborn
- Faculty of Medicine, Health and Life Sciences, Queen's University Belfast, BT9 6AG, Northern Ireland..
| | - Tanja Gonska
- Department of Pediatrics, University of Toronto and Research Institute, Hospital for Sick Children, Toronto, Canada.
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