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Kogiso T, Ogasawara Y, Taniai M, Shimada E, Inai K, Tokushige K, Nakai Y. Importance of gamma-glutamyl transferase elevation in patients with Fontan-associated liver disease. Hepatol Res 2024. [PMID: 38985389 DOI: 10.1111/hepr.14093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/07/2024] [Accepted: 06/17/2024] [Indexed: 07/11/2024]
Abstract
AIM In patients with Fontan-associated liver disease (FALD), gamma-glutamyl transferase (GGT) levels are often elevated, however, its clinical importance is unclear. We investigated the relationship between the clinical course of FALD and GGT levels. METHODS We enrolled 145 patients with FALD who underwent right-heart catheterization (RHC) and visited our department. Ursodeoxycholic acid (UDCA) was administered to 62 of the patients. Patients with GGT levels <50 and ≥50 U/L were compared. Follow-up RHC was undertaken in 76 patients. Cases in which GGT levels decreased by ≥10% or <50 U/L were defined as improved (n = 33). RESULTS Patients with GGT levels ≥50 U/L had significantly lower levels of albumin and higher levels of alanine transaminase (ALT) but no significant differences in RHC factors. Over a 4.6-year period, 43.4% showed improvement in GGT levels. Improved cases had significantly lower total bilirubin (1.1 vs. 1.6 mg/dL), AST (22 vs. 28 U/L), and ALT (18 vs. 27 U/L) levels than nonimproved cases (n = 29, p < 0.05), and the change in platelet count (-0.5 vs. -3.0 × 10-4/μL) was significantly lower in the latter (p = 0.03). The improvement rate was significantly higher in UDCA-treated cases (55.2%) with GGT levels ≥50 U/L compared to cases not treated with UDCA (18.2%, p = 0.04). CONCLUSION In cases of FALD with no improvement in GGT level, the platelet count decreased over time, suggesting progression of fibrosis. Physicians should be aware of the importance of a high GGT level in patients with FALD.
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Affiliation(s)
- Tomomi Kogiso
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yuri Ogasawara
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Makiko Taniai
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Eriko Shimada
- Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kei Inai
- Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Katsutoshi Tokushige
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yousuke Nakai
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
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Hitawala AA, Gopalakrishna H, Mironova M, Livinski AA, Wright EC, Downing T, Ito S, Fisher SD, Cedars AM, John AS, Heller T. Meta-analysis: Incidence of cirrhosis and hepatocellular carcinoma in patients with Fontan palliation. Aliment Pharmacol Ther 2024; 59:1020-1032. [PMID: 38497159 DOI: 10.1111/apt.17952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/10/2023] [Accepted: 03/03/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND AND AIMS The Fontan palliation is the final stage of surgery for many children born with univentricular physiology. Almost all Fontan patients develop liver fibrosis which may eventually lead to cirrhosis and hepatocellular carcinoma (HCC). These are important causes of morbidity and mortality in these patients. We performed a systematic review and meta-analysis to assess the incidence of cirrhosis and HCC in Fontan patients and stratify it based on time since surgery. METHODS A literature search of seven databases identified 1158 records. Studies reporting the number of cirrhosis and HCC cases in Fontan patients and time since Fontan surgery were included. In the cirrhosis cohort, we included only those studies where all patients underwent liver biopsy. RESULTS A total of 23 studies were included: 12 and 13 studies in the cirrhosis and HCC cohorts, respectively, with two studies included in both cohorts. The incidence of cirrhosis was 0.97 per 100 patient-years (95% CI 0.57-1.63), with the incidence and cumulative incidence ≥20 years post Fontan surgery being 1.61 per 100 patient-years (95% CI 1.24-2.08) and 32.2% (95% CI 25.8%-39.4%), respectively. The incidence of HCC was 0.12 per 100 patient-years (95% CI 0.07-0.21), with the incidence and cumulative incidence ≥20 years post Fontan surgery being 0.20 per 100 patient-years (95% CI 0.12-0.35) and 3.9% (95% CI 2.2%-6.8%), respectively. Only about 70% of patients with HCC (20/28) had underlying cirrhosis. CONCLUSION The incidence of cirrhosis and HCC increases over time, especially at ≥20 years post Fontan surgery. Studies are needed to further identify at-risk patients in order to streamline surveillance for these highly morbid conditions.
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Affiliation(s)
- Asif A Hitawala
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Harish Gopalakrishna
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Maria Mironova
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Alicia A Livinski
- National Institutes of Health Library, Office of Research Services, Office of the Director, National Institutes of Health, Bethesda, Maryland, USA
| | - Elizabeth C Wright
- Office of the Director, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Tacy Downing
- Division of Pediatric Cardiology, Children's National Hospital, Washington, DC, USA
| | - Seiji Ito
- Division of Pediatric Cardiology, Children's National Hospital, Washington, DC, USA
| | - Stacy D Fisher
- Adult Congenital Heart Disease Center, Johns Hopkins Heart and Vascular Institute, Baltimore, Maryland, USA
| | - Ari M Cedars
- Adult Congenital Heart Disease Center, Johns Hopkins Heart and Vascular Institute, Baltimore, Maryland, USA
| | - Anitha S John
- Division of Pediatric Cardiology, Children's National Hospital, Washington, DC, USA
| | - Theo Heller
- Translational Hepatology Section, Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Kogiso T, Takayanagi K, Ishizuka T, Otsuka M, Inai K, Ogasawara Y, Horiuchi K, Taniai M, Tokushige K. Serum level of full-length connective tissue growth factor reflects liver fibrosis stage in patients with Fontan-associated liver disease. PLoS One 2024; 19:e0296375. [PMID: 38166061 PMCID: PMC10760884 DOI: 10.1371/journal.pone.0296375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/11/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Chronic liver disease leads to liver fibrosis, and an accurate diagnosis of the fibrosis stage is crucial for medical management. Connective tissue growth factor (CTGF) is produced by endothelial cells and platelets and plays a central role in inducing fibrosis in various organs. In the present study, we tested the validity of measuring the serum levels of two types of CTGF to estimate the biopsy-confirmed liver fibrosis stage. METHODS We used two detection antibodies targeting the N- and C-terminal of CTGF to measure the serum levels of two forms of CTGF consisting of its full length and its N-terminal fragment. We analyzed the level of CTGF (via enzyme-linked immunosorbent assay) and the liver fibrosis stage in 38 patients with Fontan-associated liver disease (FALD) (26 cases of which were diagnosed pathologically). Correlations were determined by multivariate analysis and the area under the receiver operating characteristic curve. The 65 patients with nonalcoholic fatty liver disease (NAFLD) were included as a disease control group for examination. RESULTS Full-length CTGF was significantly inversely correlated with liver fibrosis in patients with FALD. Although the platelet count was also associated with the liver fibrosis stage, full-length CTGF was more closely correlated with the fibrosis stage. Furthermore, the level of full-length CTGF was inversely associated with high central venous pressure. Conversely, the serum level of CTGF was not correlated with the fibrosis stage in NAFLD. CONCLUSION The serum level of full-length CTGF may be useful for estimating the liver fibrosis stage in patients with FALD.
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Affiliation(s)
- Tomomi Kogiso
- Institute of Gastroenterology, Department of Internal Medicine, Tokyo Women’s Medical University, Tokyo, Japan
| | - Kayo Takayanagi
- Division of Transplant Immunology, Central Clinical Laboratories, Tokyo Women’s Medical University, Tokyo, Japan
| | - Tsutomu Ishizuka
- Division of Transplant Immunology, Central Clinical Laboratories, Tokyo Women’s Medical University, Tokyo, Japan
| | - Motoyuki Otsuka
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Kei Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yuri Ogasawara
- Institute of Gastroenterology, Department of Internal Medicine, Tokyo Women’s Medical University, Tokyo, Japan
| | - Kentaro Horiuchi
- Institute of Gastroenterology, Department of Internal Medicine, Tokyo Women’s Medical University, Tokyo, Japan
| | - Makiko Taniai
- Institute of Gastroenterology, Department of Internal Medicine, Tokyo Women’s Medical University, Tokyo, Japan
| | - Katsutoshi Tokushige
- Institute of Gastroenterology, Department of Internal Medicine, Tokyo Women’s Medical University, Tokyo, Japan
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Kogiso T, Sagawa T, Taniai M, Shimada E, Inai K, Shinohara T, Tokushige K. Risk factors for Fontan-associated hepatocellular carcinoma. PLoS One 2022; 17:e0270230. [PMID: 35714161 PMCID: PMC9205474 DOI: 10.1371/journal.pone.0270230] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 06/07/2022] [Indexed: 11/18/2022] Open
Abstract
Aims The incidence of hepatocellular carcinoma (HCC) in patients with Fontan-associated liver disease (i.e., FALD-HCC) has increased over time. However, the risk factors for HCC development remain unclear. Here, we compared the levels of non-invasive markers to the survival rate of FALD-HCC patients. Methods From 2003 to 2021, 154 patients (66 men, 42.9%) developed liver disease after undergoing Fontan procedures. HCC was diagnosed in 15 (9.7%) (8 men, 53.3%) at a median age of 34 years (range, 21–45 years). We compared FALD-HCC and non-HCC cases; we generated marker level cutoffs using receiver operating characteristic curves. We sought to identify risk factors for HCC and mortality. Results The incidence of HCC was 4.9% in FALD patients within 20 years after the Fontan procedure. Compared with non-HCC patients, FALD-HCC patients exhibited higher incidences of polysplenia and esophageal varices. At the time of HCC development, the hyaluronic acid (HA) level (p = 0.04) and the fibrosis-4 index (p = 0.02) were significantly higher in FALD-HCC patients than in non-HCC patients; the total bilirubin (T-BIL) level (p = 0.07) and the model for end-stage liver disease score [excluding the international normalized ratio (MELD-XI)] (p = 0.06) tended to be higher in FALD-HCC patients. Within approximately 20 years of the Fontan procedure, 10 patients died (survival rate, 96.9%). Kaplan–Meier curve analysis indicated that patients with T-BIL levels ≥ 2.2 mg/dL, HA levels ≥ 55.5 ng/mL, and MELD-XI scores ≥ 18.7 were at high risk of HCC, a generally poor prognosis, and both polysplenia and esophageal varices. Multivariate Cox regression analyses indicated that the complication of polysplenia [Hazard ratio (HR): 10.915] and a higher MELD-XI score (HR: 1.148, both p < 0.01) were independent risk factors for FALD-HCC. Conclusions The complication of polysplenia and a MELD-XI score may predict HCC development and mortality in FALD patients.
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Affiliation(s)
- Tomomi Kogiso
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
- * E-mail:
| | - Takaomi Sagawa
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
| | - Makiko Taniai
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
| | - Eriko Shimada
- Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
| | - Kei Inai
- Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
| | - Tokuko Shinohara
- Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
| | - Katsutoshi Tokushige
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
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