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Sutton H, Karpen SJ, Kamath BM. Pediatric Cholestatic Diseases: Common and Unique Pathogenic Mechanisms. ANNUAL REVIEW OF PATHOLOGY 2024; 19:319-344. [PMID: 38265882 DOI: 10.1146/annurev-pathmechdis-031521-025623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Cholestasis is the predominate feature of many pediatric hepatobiliary diseases. The physiologic flow of bile requires multiple complex processes working in concert. Bile acid (BA) synthesis and excretion, the formation and flow of bile, and the enterohepatic reuptake of BAs all function to maintain the circulation of BAs, a key molecule in lipid digestion, metabolic and cellular signaling, and, as discussed in the review, a crucial mediator in the pathogenesis of cholestasis. Disruption of one or several of these steps can result in the accumulation of toxic BAs in bile ducts and hepatocytes leading to inflammation, fibrosis, and, over time, biliary and hepatic cirrhosis. Biliary atresia, progressive familial intrahepatic cholestasis, primary sclerosing cholangitis, and Alagille syndrome are four of the most common pediatric cholestatic conditions. Through understanding the commonalities and differences in these diseases, the important cellular mechanistic underpinnings of cholestasis can be greater appreciated.
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Affiliation(s)
- Harry Sutton
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada;
| | - Saul J Karpen
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Binita M Kamath
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada;
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El Raichani N, Thibault M, Alvarez F, Lavoie JC, Mohamed I. The effects of gestational age on neonatal cholestasis: A retrospective cohort study. J Neonatal Perinatal Med 2024; 17:101-110. [PMID: 38251066 DOI: 10.3233/npm-230034] [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] [Indexed: 01/23/2024]
Abstract
BACKGROUND Reference guidelines for neonatal conjugated hyperbilirubinemia (cholestasis) management use a uniform approach regardless of gestational age (GA). We hypothesize that the clinical pattern of neonatal cholestasis is tightly related to GA. The aim of this study was to describe the effects of GA on neonatal cholestasis. METHODS A retrospective 4-year cohort study in a 70-bed neonatal care unit. Neonates with conjugated bilirubin≥34.2μmol/L (2 mg/dL) were identified. The incidence, clinical characteristics, etiology, treatment, and prognosis were compared between infants <32 and≥32 weeks GA. RESULTS Overall incidence of cholestasis was 4% (125/3402). It was >5 times higher and the mean duration was >1.5 times longer in neonates <32 weeks GA (10% versus 1.8%, p <0.01 and 49 versus 31 days, p <0.01, respectively). The onset of cholestasis was later in neonates <32 weeks (22 versus 10 days of life, p <0.001). This later onset of cholestasis was associated with parenteral nutrition, whereas the earlier onset was associated with other causes. Treatment using fish oil lipids was more frequently administrated to infants <32 weeks GA, whereas Ursodeoxycholic acid was administrated more frequently in≥32 weeks GA. Cholestasis resolved during hospitalization in 73% of <32 versus 38% in≥32 weeks GA infants (p <0.01). CONCLUSIONS The incidence, clinical presentation, etiology, treatment, and clinical evolution of neonatal cholestasis were all significantly affected by GA. Our results support the use of a GA-oriented approach for the management of neonatal cholestasis.
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Affiliation(s)
- N El Raichani
- Department of Nutrition, University of Montreal, Montreal, QC, Canada
| | - M Thibault
- Department of Pharmacy, CHU Sainte-Justine, Montreal, QC, Canada
| | - F Alvarez
- Department of Pediatrics-Gastroenterology, Hepatology and Nutrition, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - J-C Lavoie
- Department of Nutrition, University of Montreal, Montreal, QC, Canada
- Departments of Pediatrics-Neonatology, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - I Mohamed
- Department of Nutrition, University of Montreal, Montreal, QC, Canada
- Departments of Pediatrics-Neonatology, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
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Jin M, Cui J, Ning H, Wang M, Liu W, Yao K, Yuan J, Zhong X. Alterations in gut microbiota and metabolite profiles in patients with infantile cholestasis. BMC Microbiol 2023; 23:357. [PMID: 37980506 PMCID: PMC10656868 DOI: 10.1186/s12866-023-03115-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 11/06/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND Infantile cholestasis (IC) is the most common hepatobiliary disease in infants, resulting in elevated direct bilirubin levels. Indeed, hepatointestinal circulation impacts bile acid and bilirubin metabolism. This study evaluates changes in the gut microbiota composition in children with IC and identifies abnormal metabolite profiles associated with microbial alterations. RESULTS The gut microbiota in the IC group exhibits the higher abundance of Veillonella, Streptococcus and Clostridium spp. (P < 0.05), compared to healthy infants (CON) group. Moreover, the abundance of Ruminococcus, Vibrio butyricum, Eubacterium coprostanogenes group, Intestinibacter, and Faecalibacterium were lower (P < 0.05). In terms of microbiota-derived metabolites, the levels of fatty acids (palmitoleic, α-linolenic, arachidonic, and linoleic) (P < 0.05) increased and the levels of amino acids decreased in IC group. Furthermore, the abundances of Ruminococcus, Eubacterium coprostanoligenes group, Intestinibacter and Butyrivibrio are positively correlated with proline, asparagine and aspartic acid, but negatively correlated with the α-linolenic acid, linoleic acid, palmitoleic acid and arachidonic acid. For analysis of the relationship between the microbiota and clinical index, it was found that the abundance of Veillonella and Streptococcus was positively correlated with serum bile acid content (P < 0.05), while APTT, PT and INR were negatively correlated with Faecalibalum and Ruminococcus (P < 0.05). CONCLUSION Microbiota dysbiosis happened in IC children, which also can lead to the abnormal metabolism, thus obstructing the absorption of enteral nutrition and aggravating liver cell damage. Veillonella, Ruminococcus and Butyrivibrio may be important microbiome related with IC and need further research.
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Affiliation(s)
- Meng Jin
- Gastroenterology Department, Children's Hospital Capital Institute of Pediatrics, Beijing, 100020, China
| | - Jinghua Cui
- Bacteriology Department, Capital Institute of Pediatrics, Beijing, 100020, China
| | - Huijuan Ning
- Gastroenterology Department, Children's Hospital Capital Institute of Pediatrics, Beijing, 100020, China
| | - Meijuan Wang
- Gastroenterology Department, Children's Hospital Capital Institute of Pediatrics, Beijing, 100020, China
| | - Wenwen Liu
- Gastroenterology Department, Children's Hospital Capital Institute of Pediatrics, Beijing, 100020, China
| | - Kunyu Yao
- Gastroenterology Department, Children's Hospital Capital Institute of Pediatrics, Beijing, 100020, China
| | - Jing Yuan
- Bacteriology Department, Capital Institute of Pediatrics, Beijing, 100020, China.
| | - Xuemei Zhong
- Gastroenterology Department, Children's Hospital Capital Institute of Pediatrics, Beijing, 100020, China.
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Demir HB, Umman V, Gümüs T, Tunalı S, Barut D, Karakoyun M, Akarca US. Comparison of Liver Transplant Outcomes in Biliary Atresia Patients, Considering Whether They Underwent the Kasai Procedure Beforehand: A Single Center Analysis of 72 Patients. Transplant Proc 2023:S0041-1345(23)00315-9. [PMID: 37308339 DOI: 10.1016/j.transproceed.2023.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/15/2023] [Accepted: 04/25/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND This study examines the results of liver transplantation (LT) in patients with biliary atresia, considering whether they underwent the Kasai procedure beforehand. LT and determine postoperative and long-term graft outcomes. METHODS This single-center, retrospective study included 72 pediatric patients diagnosed with postpartum biliary atresia who underwent LT between 2010 and 2022. We included patients who underwent LT either after or without the Kasai procedure and compared the demographic data of the patients with various factors, such as the Pediatric End-Stage Liver Disease scores and laboratory values. RESULTS The study included 72 patients, with 39 of them being female (54.2%) and 33 of them being male (45.8%). Of the 72 patients in the study, 47 (65.3%) had undergone the Kasai procedure, and 25 (34.7%) had not. The preoperative and postoperative month 1 bilirubin values were lower in patients who underwent the Kasai procedure and were higher in postoperative months 3 and 6. Preoperative bilirubin values, postoperative month 3 bilirubin values, and preoperative albumin values were higher in patients who developed mortality (P < .05). Cold ischemia time was longer in patients who developed mortality (P < .05). CONCLUSIONS Our study showed a higher mortality rate in patients who underwent the Kasai procedure. The results also showed that LT was more effective in children, as patients with Kasai had higher mean bilirubin values and higher preoperative albumin values than patients without Kasai.
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Affiliation(s)
| | - Veysel Umman
- Department of General Surgery, Ege University Hospital, Izmir, Turkey
| | - Tufan Gümüs
- Department of General Surgery, Ege University Hospital, Izmir, Turkey
| | - Sarp Tunalı
- Department of General Surgery, Ege University Hospital, Izmir, Turkey
| | - Doğan Barut
- Department of Pediatry, Ege University Hospital, Izmir, Turkey
| | - Miray Karakoyun
- Department of Pediatry, Ege University Hospital, Izmir, Turkey
| | - Ulus Salih Akarca
- Department of Gastroenterology, Ege University Hospital, Izmir, Turkey
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Perinatal exposure to UDCA prevents neonatal cholestasis in Cyp2c70 -/- mice with human-like bile acids. Pediatr Res 2022; 93:1582-1590. [PMID: 36151295 PMCID: PMC10172110 DOI: 10.1038/s41390-022-02303-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 07/15/2022] [Accepted: 08/24/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cyp2c70-/- mice with a human-like bile acid (BA) composition display features of neonatal cholestasis. We assessed whether perinatal ursodeoxycholic acid (UDCA) exposure prevents neonatal cholestasis in Cyp2c70-/- mice and reduces cholangiopathy development later in life. METHODS Cyp2c70+/- males were crossed with Cyp2c70+/- females fed either a regular chow diet or a 0.1% UDCA-containing diet during breeding, gestation, and suckling. Cholestasis and liver function parameters were assessed in their Cyp2c70-/- and wild-type offspring at 3 and 8 weeks of age. RESULTS Three-week-old Cyp2c70-/- pups showed features of neonatal cholestasis, including elevated plasma BAs and transaminases, which were completely prevented in Cyp2c70-/- pups upon perinatal UDCA exposure. In addition, UDCA administration to the dams corrected altered hepatic gene expression patterns in Cyp2c70-/- pups, reduced markers of fibrogenesis and inflammation, and prevented cholangiocyte proliferation. Yet, these beneficial effects of perinatal UDCA exposure were not retained into adulthood upon discontinuation of treatment. CONCLUSION Perinatal exposure of Cyp2c70-/- mice to UDCA has beneficial effects on liver function parameters, supporting a direct role of BA hydrophobicity in the development of neonatal cholestasis in these mice. However, prevention of neonatal cholestasis in Cyp2c70-/- mice has no long-lasting effects on liver pathophysiology. IMPACT This is the first study showing that perinatal UDCA exposure prevents features of neonatal cholestasis that are observed in mice with a human-like bile acid composition, i.e., Cyp2c70-/- mice. Perinatal UDCA exposure of Cyp2c70-/- pups leads to UDCA enrichment in their circulating bile acid pool and, consequently, to a reduced hydrophobicity of biliary bile acids. Perinatal UDCA exposure of Cyp2c70-/- pups has no long-lasting effects on the development of cholangiopathy after discontinuation of treatment. The results in this study expand current knowledge regarding acute and long-lasting effects of UDCA treatment in early life.
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Mahmud S, Gulshan J, Parvez M, Tasneem F, Ahmed SS. Etiology and outcome of neonatal cholestasis: an experience in a tertiary center of Bangladesh. EGYPTIAN LIVER JOURNAL 2022. [DOI: 10.1186/s43066-021-00168-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Neonatal cholestasis (NC) is a major cause of morbidity and mortality in young infants. This study examines the etiology of NC and its outcome during 2 years of follow-up at a tertiary referral center in Bangladesh.
Results
Out of 80 cholestatic infants, 60% had intrahepatic cholestasis with a mean age of onset of 12.4±2.8 days and a mean age of admission of 82.4±29.0 days. The remaining 40% were extrahepatic with a mean age of onset of 6.7±2.3 days and a mean age of admission of 94.6±50.4 days. Biliary atresia (BA), idiopathic neonatal hepatitis (INH), and TORCH (Toxoplasma, rubella, cytomegalovirus, and herpes simplex) infection except rubella were the most common causes. After receiving treatment, 46.2% of the cases improved, 23.8% deteriorated with morbidity, and 30% died. The majority of the children with INH, TORCH, choledochal cyst, hypothyroidism, galactosemia, and urinary tract infection (UTI) with sepsis were improved. Significant mortality was found in BA (56.6%), intrahepatic bile duct paucity (PIBD) (100%), and progressive familial intrahepatic cholestasis (PFIC) (100%) whereas the rest of BA (43.4%) live with persistent morbidity. Significant clinical improvement was observed in 37 (46.2%) cases of cholestasis evidenced by decreasing jaundice, change of color of urine from dark to normal color, change of stool color from pale to yellow, and gradual decrease in liver size from hepatomegaly state. In addition, decreasing median total bilirubin, direct bilirubin, alanine transaminase, gamma-glutamyl transferase, and alkaline phosphatase showed biochemical improvement at 2 years follow-up. The age of admission, etiology, and presence of ascites are the predictors of outcomes.
Conclusion
BA was the most common cause of extrahepatic while INH and TORCH infection were the most common cause of intrahepatic cholestasis. Majority of children with intrahepatic cholestasis improved but deteriorated with BA and genetic causes. Prompt referral and early diagnosis as well as the etiology of NC were the main determinants of the favorable outcome.
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Ranucci G, Della Corte C, Alberti D, Bondioni MP, Boroni G, Calvo PL, Cananzi M, Candusso M, Clemente MG, D'Antiga L, Degrassi I, De Ville De Goyet J, Di Dato F, Di Giorgio A, Vici CD, Ferrari F, Francalanci P, Fuoti M, Fusaro F, Gaio P, Grimaldi C, Iascone M, Indolfi G, Iorio R, Maggiore G, Mandato C, Matarazzo L, Monti L, Mosca F, Nebbia G, Nuti F, Paolella G, Pinon M, Roggero P, Sciveres M, Serranti D, Spada M, Vajro P, Nicastro E. Diagnostic approach to neonatal and infantile cholestasis: A position paper by the SIGENP liver disease working group. Dig Liver Dis 2022; 54:40-53. [PMID: 34688573 DOI: 10.1016/j.dld.2021.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/23/2021] [Accepted: 09/12/2021] [Indexed: 12/11/2022]
Abstract
Neonatal and infantile cholestasis (NIC) can represent the onset of a surgically correctable disease and of a genetic or metabolic disorder worthy of medical treatment. Timely recognition of NIC and identification of the underlying etiology are paramount to improve outcomes. Upon invitation by the Italian National Institute of Health (ISS), an expert working grouped was formed to formulate evidence-based positions on current knowledge about the diagnosis of NIC. A systematic literature search was conducted to collect evidence about epidemiology, etiology, clinical aspects and accuracy of available diagnostic tests in NIC. Evidence was scored using the GRADE system. All recommendations were approved by a panel of experts upon agreement of at least 75% of the members. The final document was approved by all the panel components. This position document summarizes the collected statements and defines the best-evidence diagnostic approach to cholestasis in the first year of life.
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Affiliation(s)
- Giusy Ranucci
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital AORN, Naples, Italy
| | - Claudia Della Corte
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Maria Pia Bondioni
- Pediatric Radiology, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | | | - Pier Luigi Calvo
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliera-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Mara Cananzi
- Unit of Gastroenterology, Digestive Endoscopy, Hepatology and Care of Children with Liver Transplantation, University Hospital of Padova, Padova, Italy
| | - Manila Candusso
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maria Grazia Clemente
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Lorenzo D'Antiga
- Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Irene Degrassi
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jean De Ville De Goyet
- Pediatric Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, ISMETT UPMC, Palermo, Italy
| | - Fabiola Di Dato
- Department di Translational Medical Science, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Angelo Di Giorgio
- Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Carlo Dionisi Vici
- Division of Metabolism and Metabolic Diseases Research Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Paola Francalanci
- Department of Pathology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maurizio Fuoti
- Pediatric Gastroenterology and Endoscopy Unit Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Fabio Fusaro
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Paola Gaio
- Unit of Gastroenterology, Digestive Endoscopy, Hepatology and Care of Children with Liver Transplantation, University Hospital of Padova, Padova, Italy
| | - Chiara Grimaldi
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maria Iascone
- Medical Genetics Laboratory, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Indolfi
- Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Raffaele Iorio
- Department di Translational Medical Science, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giuseppe Maggiore
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Claudia Mandato
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital AORN, Naples, Italy
| | | | - Lidia Monti
- Department of Radiology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gabriella Nebbia
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Nuti
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Paolella
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michele Pinon
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliera-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Paola Roggero
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Sciveres
- Pediatric Hepatology and Liver Transplantation, ISMETT UPMC, Palermo, Italy
| | - Daniele Serranti
- Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Pietro Vajro
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana" University of Salerno, Baronissi, Italy
| | - Emanuele Nicastro
- Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
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Abstract
Cholestatic jaundice is a common presenting feature of hepatobiliary and/or metabolic dysfunction in the newborn and young infant. Timely detection of cholestasis, followed by rapid step-wise evaluation to determine the etiology, is crucial to identify those causes that are amenable to medical or surgical intervention and to optimize outcomes for all infants. In the past 2 decades, genetic etiologies have been elucidated for many cholestatic diseases, and next-generation sequencing, whole-exome sequencing, and whole-genome sequencing now allow for relatively rapid and cost-effective diagnosis of conditions not previously identifiable via standard blood tests and/or liver biopsy. Advances have also been made in our understanding of risk factors for parenteral nutrition-associated cholestasis/liver disease. New lipid emulsion formulations, coupled with preventive measures to decrease central line-associated bloodstream infections, have resulted in lower rates of cholestasis and liver disease in infants and children receiving long-term parental nutrition. Unfortunately, little progress has been made in determining the exact cause of biliary atresia. The median age at the time of the hepatoportoenterostomy procedure is still greater than 60 days; consequently, biliary atresia remains the primary indication for pediatric liver transplantation. Several emerging therapies may reduce the bile acid load to the liver and improve outcomes in some neonatal cholestatic disorders. The goal of this article is to review the etiologies, diagnostic algorithms, and current and future management strategies for infants with cholestasis.
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Affiliation(s)
- Amy G Feldman
- Digestive Health Institute, Children's Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, CO
| | - Ronald J Sokol
- Digestive Health Institute, Children's Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, CO
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Peck LH, Prusakov P, Mezoff EA. Biochemical Parameters in Extremely Preterm Infants Receiving Mixed Lipid Emulsions. J Pediatr Pharmacol Ther 2021; 26:841-849. [PMID: 34790075 DOI: 10.5863/1551-6776-26.8.841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/12/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE A mixture of soybean, medium-chain triglycerides, olive, and fish oils (SMOF) contains higher α-tocopherol and n-3 polyunsaturated fatty acids and lower phytosterol content compared with conventional soybean oil lipid emulsions (SOLE). We sought to characterize plasma total fatty acid profiles (FAPs) and assess the tolerability of long-term SMOF therapy in extremely preterm infants. METHODS We retrospectively evaluated infants born <28 weeks gestational age who received at least 30 consecutive days of SMOF between July 2016 and June 2019. We evaluated monthly FAPs and biochemical tolerance to SMOF using direct bilirubin (DB) and triglyceride (TG) levels. Growth parameters were evaluated longitudinally until discharge. RESULTS Sixteen patients with median gestational age 24 weeks (IQR, 23-25 weeks) received SMOF for median 76 days (IQR, 52-130 days). Fourteen patients had necrotizing enterocolitis (NEC) requiring surgical intervention and 15 patients received SOLE for median 19 days (IQR, 14-26 days) prior to switching to SMOF. Median docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) levels were elevated, whereas the remaining fatty acid levels fell within reported reference ranges. There were no incidents of essential fatty acid deficiency (triene to tetraene ratio >0.2) or hypertriglyceridemia (TG >200 mg/dL) with a general downtrend in DB after the first month on SMOF. All growth Z-scores declined throughout hospital stay. CONCLUSIONS Infants who received SMOF had a more pronounced elevation in DHA than EPA, of which the clinical significance remains unknown. Growth Z-scores declined with SMOF but were confounded by a high prevalence of surgically treated NEC.
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Sukwuttichai P, Boonkasidecha S, Montakantikul P, Vimolsarawong N. Efficacy comparison between oral erythromycin versus domperidone for the treatment of feeding intolerance in preterm neonates. Pediatr Neonatol 2021; 62:543-549. [PMID: 34167901 DOI: 10.1016/j.pedneo.2021.05.018] [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: 12/23/2020] [Revised: 05/17/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Domperidone and erythromycin are commonly used as prokinetic agents for feeding intolerance in preterm neonates; however, no data from a previous study have compared their efficacy. This study aimed to compare the efficacy of orally administered domperidone and erythromycin for the treatment of feeding intolerance in preterm infants. METHODS This retrospective cohort study included preterm neonates with a birthweight of <1800 g and gestational age <37 weeks. Data were collected from medical records at Queen Sirikit National Institute of Child Health (QSNICH) from 2006 to 2014. The primary outcome was the time to establish full enteral feeding (150 ml/kg/day) after starting oral domperidone or erythromycin for the treatment of feeding intolerance in preterm neonates. The secondary outcome was adverse effects associated with domperidone and erythromycin therapy. RESULTS Among the 150 preterm neonates enrolled in this study, 66 received domperidone, and 84 received erythromycin. The baseline characteristics and comorbidities were not significantly different between the two groups; however, the gestational age at birth of neonates in the domperidone group was significantly lower than that of those in the erythromycin group. The time to establish full enteral feeding did not differ between the domperidone (11 days, "IQR," [6, 17]) and erythromycin (10 days, IQR [7, 14]) groups (p = 0.622). No major adverse effects were noted. There were only three preterm infants who had elevated liver enzymes in each group, but the difference between groups was not significant. CONCLUSION From this study, the efficacy of oral domperidone was promising equivalent to oral erythromycin and seems to be one of the treatment options for feeding intolerance in preterm neonates. However, large randomized, controlled trials are needed to confirm the efficacy and safety of domperidone in this population.
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Affiliation(s)
- Pattarapan Sukwuttichai
- Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand; Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Suppawat Boonkasidecha
- Division of Neonatology, Department of Pediatrics, Queen Sirikit National Institute of Child Health, College of Medicine, Rangsit University, Bangkok, Thailand.
| | | | - Nawaporn Vimolsarawong
- Department of Pharmacy, Queen Sirikit National Institute of Child Health, Bangkok, Thailand
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Chan KWE, Lee KH, Wong HYV, Tsui SYB, Mou JWC, Tam YH. Impact of Age of Patient and Experience of Surgeon on the Outcome after Kasai Portoenterostomy: Can We Delay the Surgery? Eur J Pediatr Surg 2021; 31:335-340. [PMID: 32629495 DOI: 10.1055/s-0040-1713934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Age of patient and experience of biliary atresia (BA) center are well-known factors associated with early jaundice clearance (EJC) after Kasai portoenterostomy (KPE) in infants with BA. This study focused on the impact of age and surgeon factor on the short-term outcome after KPE within a single center. MATERIALS AND METHODS Fifty-four consecutive infants (18 boys and 36 girls) who underwent KPE from January 2010 to January 2020 were reviewed. KPE was performed in the earliest available operative session once the initial work-up was completed. In group A (n = 41), KPE was performed by surgeon A. In group B (n = 13), KPE was performed by specialists under the supervision of surgeon B (who is the mentor of surgeon A) when surgeon A was not available for operation. The demographics of patients, the EJC (total bilirubin <20 μmol/L within 6 months of KPE), and 2-year native liver survival (NLS) between the two groups were studied. RESULTS The median age at operation was 52 days (range 26-135 days). The overall EJC rate and 2-year NLS were 85.2 and 89.4%, respectively. Group A (p = 0.015) and male gender (p = 0.029) were statistically associated with EJC but not the age at operation (p = 0.101). Group A was also statistically associated with superior 2-year NLS (p = 0.047). CONCLUSION Balancing between the impact of age at operation and the experience of surgeon on the outcome after KPE, our result suggested that KPE may be deferred until a more experienced surgeon to operate.
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Affiliation(s)
- Kin Wai Edwin Chan
- Department of Surgery, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Kim Hung Lee
- Department of Surgery, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Hei Yi Vicky Wong
- Department of Surgery, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Siu Yan Bess Tsui
- Department of Surgery, The Chinese University of Hong Kong, New Territories, Hong Kong
| | | | - Yuk Him Tam
- Department of Surgery, The Chinese University of Hong Kong, New Territories, Hong Kong
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Chatterjee A, Mukherjee S, Basu B, Roy D, Basu R, Ghosh H, Mishra L, Bhattacharya M, Chakraborty N. Insight into the distinctive paradigm of Human Cytomegalovirus associated intrahepatic and extrahepatic cholestasis in neonates. Sci Rep 2020; 10:15861. [PMID: 32985571 PMCID: PMC7522230 DOI: 10.1038/s41598-020-73009-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 08/18/2020] [Indexed: 01/15/2023] Open
Abstract
Human Cytomegalovirus has been implicated as a probable cause for the development of hepatic cholestasis among neonates. Our study tried to ascertain the exact demographic, biochemical and immunological markers to differentially diagnose patients with HCMV associated intrahepatic and extrahepatic cholestasis and also decipher the phylogenetic variability among the viral strains infecting the two groups. A total of 110 neonates collected over a span of 2 years were selected for the study classified into four different groups based on the presence of hepatic cholestasis and active HCMV infection. Our analysis predicted that total Cholesterol, GGT, ALP and TNFα were the only significant biological markers with exact cut-off scores, capable of distinguishing between HCMV associated intrahepatic and extrahepatic cholestasis. We confirmed that in patients belonging to both of these groups, the inflammasome is activated and the extent of this activation is more or less same except for the initial activators NLRP3 and AIM2 respectively. When we performed two separate phylogenetic analyses with HCMV gM and gN gene sequences, we found that in both cases the sequences from the IHC and EHC groups formed almost separate phylogenetic clusters. Our study has shown that the HCMV clinical strains infecting at intrahepatic and extrahepatic sites are phylogenetically segregated as distinct clusters. These two separate groups show different physiological as well as immunological modulations while infecting a similar host.
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Affiliation(s)
- Aroni Chatterjee
- Virus Research Laboratory, ICMR-National Institute of Cholera and Enteric Diseases, GB4, ID & BG Hospital Campus, Dr. S.C Banerjee Road, Beliaghata, Kolkata, West Bengal, 700010, India
| | - Sumit Mukherjee
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Biswanath Basu
- Department of Paediatrics, N. R. S. Medical College & Hospital, Kolkata, 700014, India
| | - Debsopan Roy
- Virus Research Laboratory, ICMR-National Institute of Cholera and Enteric Diseases, GB4, ID & BG Hospital Campus, Dr. S.C Banerjee Road, Beliaghata, Kolkata, West Bengal, 700010, India
| | - Rivu Basu
- Department of Community Medicine, R. G. Kar Medical College and Hospital, Kolkata, 700004, India
| | - Hiya Ghosh
- Department of Endocrinology and Metabolism, IPGMER & SSKM Hospital, Kolkata, 700020, India
| | - Lopamudra Mishra
- Department of Paediatrics, Dr. B. C. Roy Post Graduate Institute of Paediatric Sciences, Kolkata, 700054, India
| | - Mala Bhattacharya
- Department of Paediatrics, Dr. B. C. Roy Post Graduate Institute of Paediatric Sciences, Kolkata, 700054, India
| | - Nilanjan Chakraborty
- Virus Research Laboratory, ICMR-National Institute of Cholera and Enteric Diseases, GB4, ID & BG Hospital Campus, Dr. S.C Banerjee Road, Beliaghata, Kolkata, West Bengal, 700010, India.
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13
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Abstract
Neonatal cholestasis is characterized by conjugated hyperbilirubinemia in the newborn and young infant and is a sign common to over 100 hepatobiliary and/or metabolic disorders. A timely evaluation for its etiology is critical in order to quickly identify treatable causes such as biliary atresia, many of which benefit from early therapy. An expanding group of molecularly defined disorders involving bile formation, canalicular transporters, tight junction proteins and inborn errors of metabolism are being continuously discovered because of advances in genetic testing and bioinformatics. The advent of next generation sequencing has transformed our ability to test for multiple genes and whole exome or whole genome sequencing within days to weeks, enabling rapid and affordable molecular diagnosis for disorders that cannot be directly diagnosed from standard blood tests or liver biopsy. Thus, our diagnostic algorithms for neonatal cholestasis are undergoing transformation, moving genetic sequencing to earlier in the evaluation pathway once biliary atresia, "red flag" disorders and treatable disorders are excluded. Current therapies focus on promoting bile flow, reducing pruritus, ensuring optimal nutrition, and monitoring for complications, without addressing the underlying cause of cholestasis in most instances. Our improved understanding of bile formation and the enterohepatic circulation of bile acids has led to emerging therapies for cholestasis which require appropriate pediatric clinical trials. Despite these advances, the cause and optimal therapy for biliary atresia remain elusive. The goals of this review are to outline the etiologies, diagnostic pathways and current and emerging management strategies for neonatal cholestasis.
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Affiliation(s)
- Amy G. Feldman
- Pediatric Liver Center, Digestive Health Institute, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ronald J. Sokol
- Pediatric Liver Center, Digestive Health Institute, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colorado, USA,Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA,Corresponding Author: Ronald J. Sokol, Digestive Health Institute, Children’s Hospital Colorado, Box B290, 13123 E. 16th Ave., Aurora, Colorado, 80045, USA Phone: 720-777-6669, Fax: 720-777-7277,
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Normal Gamma Glutamyl Transferase Levels at Presentation Predict Poor Outcome in Biliary Atresia. J Pediatr Gastroenterol Nutr 2020; 70:350-355. [PMID: 31738295 DOI: 10.1097/mpg.0000000000002563] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Gamma-glutamyl transferase levels (GGT) are typically elevated in biliary atresia (BA), but normal GGT levels have been observed. This cohort of "normal GGT" BA has neither been described nor has the prognostic value of GGT level on outcomes in BA. We aimed to describe outcomes of a single-centre Australian cohort of infants with BA and assess the impact of GGT level at presentation on outcomes in BA. METHODS Infants diagnosed with BA between 1991 and 2017 were retrospectively analysed. Outcomes were defined as survival with native liver, liver transplantation (LT), and death. Patients were categorized into normal (<200I U/L) or high GGT groups based on a mean of 3 consecutive GGT values done before Kasai portoenterostomy (KPE). Baseline parameters, age at surgery, clearance of jaundice (COJ), and outcomes were compared between the 2 groups. RESULTS One hundred thirteen infants underwent KPE at median 61 (30-149) days. At a median follow-up of 14.2 (0.9-26.3) years, 35% (39/113) patients were surviving with native liver, 55% (62/113) underwent LT and 11% (12/113) died pretransplant. 12.3% (14/113) patients had normal GGT. Age at KPE and time to COJ were similar between normal and high GGT groups. Normal GGT group had shorter time from KPE to LT (11 vs 18 months, P = 0.02), underwent LT at a younger age (14 vs 20 months, P = 0.04), and had poorer transplant-free survival (P = 0.04) than high GGT group. CONCLUSIONS 12.3% of infants with BA had normal GGT levels at diagnosis. Low GGT levels at presentation in BA was associated with a poorer outcome.
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Clément F, Grinspon RP, Yankelevich D, Martín Benítez S, De La Ossa Salgado MC, Ropelato MG, Ballerini MG, Keselman AC, Braslavsky D, Pennisi P, Bergadá I, Finkielstain GP, Rey RA. Development and Validation of a Prediction Rule for Growth Hormone Deficiency Without Need for Pharmacological Stimulation Tests in Children With Risk Factors. Front Endocrinol (Lausanne) 2020; 11:624684. [PMID: 33613456 PMCID: PMC7887303 DOI: 10.3389/fendo.2020.624684] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/14/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Practice guidelines cannot recommend establishing a diagnosis of growth hormone deficiency (GHD) without performing growth hormone stimulation tests (GHST) in children with risk factors, due to the lack of sufficient evidence. OBJECTIVE Our goal was to generate an evidence-based prediction rule to diagnose GHD in children with growth failure and clinically identifiable risk factors. METHODS We studied a cohort of children with growth failure to build the prediction model, and a second, independent cohort to validate the prediction rule. To this end, we assessed the existence of: pituitary dysgenesis, midline abnormalities, (supra)sellar tumor/surgery, CNS infection, traumatic brain injury, cranial radiotherapy, chemotherapy, genetic GHD, pituitary hormone deficiencies, and neonatal hypoglycemia, cholestasis, or hypogenitalism. Selection of variables for model building was performed using artificial intelligence protocols. Specificity of the prediction rule was the main outcome measure in the validation set. RESULTS In the first cohort (n=770), the resulting prediction rule stated that a patient would have GHD if (s)he had: pituitary dysgenesis, or two or more anterior pituitary deficiencies, or one anterior pituitary deficiency plus: neonatal hypoglycemia or hypogenitalism, or diabetes insipidus, or midline abnormalities, or (supra)sellar tumor/surgery, or cranial radiotherapy ≥18 Gy. In the validation cohort (n=161), the specificity of the prediction rule was 99.2% (95% CI: 95.6-100%). CONCLUSIONS This clinical rule predicts the existence of GHD with high specificity in children with growth disorders and clinically identifiable risk factors, thus providing compelling evidence to recommend that GHD can be safely diagnosed without recurring to GHST in neonates and children with growth failure and specific comorbidities.
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Affiliation(s)
- Florencia Clément
- Centro de Investigaciones Endocrinológicas “Dr César Bergadá” (CEDIE), CONICET-FEI-División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Romina P. Grinspon
- Centro de Investigaciones Endocrinológicas “Dr César Bergadá” (CEDIE), CONICET-FEI-División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Daniel Yankelevich
- Practia S.A., Buenos Aires, Argentina
- Fundación para el Desarrollo Argentino (FUNDAR), Buenos Aires, Argentina
| | | | - María Carolina De La Ossa Salgado
- Centro de Investigaciones Endocrinológicas “Dr César Bergadá” (CEDIE), CONICET-FEI-División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - María Gabriela Ropelato
- Centro de Investigaciones Endocrinológicas “Dr César Bergadá” (CEDIE), CONICET-FEI-División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - María Gabriela Ballerini
- Centro de Investigaciones Endocrinológicas “Dr César Bergadá” (CEDIE), CONICET-FEI-División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Ana C. Keselman
- Centro de Investigaciones Endocrinológicas “Dr César Bergadá” (CEDIE), CONICET-FEI-División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Débora Braslavsky
- Centro de Investigaciones Endocrinológicas “Dr César Bergadá” (CEDIE), CONICET-FEI-División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Patricia Pennisi
- Centro de Investigaciones Endocrinológicas “Dr César Bergadá” (CEDIE), CONICET-FEI-División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Ignacio Bergadá
- Centro de Investigaciones Endocrinológicas “Dr César Bergadá” (CEDIE), CONICET-FEI-División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Gabriela P. Finkielstain
- Centro de Investigaciones Endocrinológicas “Dr César Bergadá” (CEDIE), CONICET-FEI-División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
- Takeda Pharma, Buenos Aires, Argentina
| | - Rodolfo A. Rey
- Centro de Investigaciones Endocrinológicas “Dr César Bergadá” (CEDIE), CONICET-FEI-División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
- *Correspondence: Rodolfo A. Rey,
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Ghazy RM, Khedr MA. Neonatal cholestasis: recent insights. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2019. [DOI: 10.1186/s43054-019-0009-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractBackgroundNeonatal physiological jaundice is a common benign condition that rarely extends behind the second week of life; however, it may interfere with the diagnosis of a pathological condition termed neonatal cholestasis (NC). The latter is a critical, uncommon problem characterized by conjugated hyperbilirubinaemia. This review aims to highlight the differences between physiological and pathological jaundice, identify different causes of NC, and provide a recent approach to diagnosis and management of this serious condition.Main textNC affects 1/2500 live births, resulting in life-threatening complications due to associated hepatobiliary or metabolic abnormalities. NC is rarely benign and indicates the presence of severe underlying disease. If jaundice extends more than 14 days in full-term infants or 21 days in preterm infants, the serum bilirubin level fractionated into conjugated (direct) and unconjugated (indirect) bilirubin should be measured. A stepwise diagnostic approach starts with obtaining a complete history, and a physical examination which are valuable for the rapid diagnosis of the underlying disease. The most frequently diagnosed causes of NC are biliary atresia (BA) and idiopathic neonatal hepatitis (INH). The early diagnosis of NC ensures more accurate management and better prognosis. Despite the unavailability of any specific treatments for some causes of NC, the patient can benefit from nutritional management and early medical intervention. Future research should attempt to shed light on methods of screening for NC, especially for causes that can be effectively treated either through proper nutritional support, appropriate chemotherapeutic management, or timely surgical intervention.ConclusionFurther attention should be paid for diagnosis and treatment of NC as it may be misdiagnosed as physiological jaundice; this may delay the proper management of the underlying diseases and aggravates its complications.
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Shaul E, Kogan-Liberman D, Schuckalo S, Jan D, Ewart M, Nguyen T, Martinez M, Ovchinsky N. Novel mutations in NOTCH2 gene in infants with neonatal cholestasis. Pediatr Rep 2019; 11:8206. [PMID: 31595186 PMCID: PMC6778839 DOI: 10.4081/pr.2019.8206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 07/29/2019] [Indexed: 02/07/2023] Open
Abstract
One cause of neonatal cholestasis (NC) is paucity of intrahepatic bile ducts which can be associated with Alagille syndrome or non- syndromic. Alagille syndrome is caused by autosomal dominant mutations in the Notch signaling pathway ligand Jagged1 in 94% of patients and mutations in the NOTCH2 receptor in <1% of patients. This is a retrospective case series studying infants with neonatal cholestasis found to have variants of unknown significance (VOUS) in NOTCH2. Sorting intolerant from tolerant (SIFT) and polymorphism phenotyping (PolyPhen) were utilized to predict a damaging effect. Five infants with NC without other features of Alagille syndrome were found to have one copy of a VOUS in NOTCH2, predicted to be damaging by SIFT and PolyPhen. Our cases support the notion that NOTCH2 mutations may result in hypoplastic biliary system. Further characterization of these variants is important to assist with our clinical approach to NC.
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Affiliation(s)
- Eliana Shaul
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY
| | - Debora Kogan-Liberman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital at Montefiore, Bronx, NY
| | - Stephanie Schuckalo
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Goryeb Children's Hospital - Atlantic Health System, Morristown, NJ
| | - Dominique Jan
- Department of Pediatric Surgery, Children's Hospital at Montefiore, Bronx, NY
| | - Michelle Ewart
- Division of Surgical Pathology, Montefiore Medical Center, Bronx, NY
| | - Trang Nguyen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital at Montefiore, Bronx, NY
| | - Mercedes Martinez
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Morgan Stanley Children's Hospital of New York, NY, USA
| | - Nadia Ovchinsky
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital at Montefiore, Bronx, NY.,Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Goryeb Children's Hospital - Atlantic Health System, Morristown, NJ
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Lyle A, Turcu R. Case 1: Severe Jaundice in a 2-day-old Term Neonate. Neoreviews 2019; 20:e464-e467. [PMID: 31371555 DOI: 10.1542/neo.20-8-e464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Allison Lyle
- Department of Graduate Medical Education, Indiana University School of Medicine, Indianapolis, IN
| | - Rodica Turcu
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY
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Feldman AG, Sokol RJ. Neonatal cholestasis: emerging molecular diagnostics and potential novel therapeutics. Nat Rev Gastroenterol Hepatol 2019; 16:346-360. [PMID: 30903105 DOI: 10.1038/s41575-019-0132-z] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Neonatal cholestasis is a group of rare disorders of impaired bile flow characterized by conjugated hyperbilirubinaemia in the newborn and young infant. Neonatal cholestasis is never physiological but rather is a sign of hepatobiliary and/or metabolic disorders, some of which might be fatal if not identified and treated rapidly. A step-wise timely evaluation is essential to quickly identify those causes amenable to treatment and to offer accurate prognosis. The aetiology of neonatal cholestasis now includes an expanding group of molecularly defined entities with overlapping clinical presentations. In the past two decades, our understanding of the molecular basis of many of these cholestatic diseases has improved markedly. Simultaneous next-generation sequencing for multiple genes and whole-exome or whole-genome sequencing now enable rapid and affordable molecular diagnosis for many of these disorders that cannot be directly diagnosed from standard blood tests or liver biopsy. Unfortunately, despite these advances, the aetiology and optimal therapeutic approach of the most common of these disorders, biliary atresia, remain unclear. The goals of this Review are to discuss the aetiologies, algorithms for evaluation and current and emerging therapeutic options for neonatal cholestasis.
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Affiliation(s)
- Amy G Feldman
- Pediatric Liver Center, Digestive Health Institute, Children's Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ronald J Sokol
- Pediatric Liver Center, Digestive Health Institute, Children's Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, CO, USA. .,Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Abstract
Biliary atresia is a progressive inflammatory sclerosing disease of the bile ducts in the neonatal liver. Without surgical intervention these patients are destined to succumb to the disease. The development of the hepatoportoenterostomy in 1959 and liver transplantation in 1963 ushered a new era of success treating these patients. While many surgical modifications and adjuncts to treatment have been attempted over the last 50 years, the mainstay of treatment to give the child the best chance at prolonged survival with the native liver is a properly performed operation, in a timely fashion, with minimal post-operative complications. This review presents the authors current practice guideline to achieve these goals.
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Affiliation(s)
- Frederick M Karrer
- Department of Pediatric Surgery, Children's Hospital Colorado, Aurora CO, USA.
| | - Jonathan P Roach
- Department of Pediatric Surgery, Children's Hospital Colorado, Aurora CO, USA
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Chang SH, Joo SM, Yoon CS, Lee KH, Lee SM. Percutaneous Transhepatic Biliary Drainage in a Two-Month-Old Infant with Inspissated Bile Syndrome. Yonsei Med J 2018; 59:904-907. [PMID: 30091325 PMCID: PMC6082986 DOI: 10.3349/ymj.2018.59.7.904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/06/2018] [Accepted: 07/15/2018] [Indexed: 11/27/2022] Open
Abstract
Inspissated bile syndrome (IBS) is a relatively rare condition. Many treatment options are available, including medication, surgery, and surgical interventions, such as insertion of cholecystostomy drain, endoscopic retrograde cholangiopancreatography, internal biliary drainage, and percutaneous transhepatic biliary drainage (PTBD). We herein report the first case of IBS that was successfully treated with PTBD in a two-month-old infant in Korea. PTBD was initiated on postnatal day 72. On postnatal day 105, we confirmed complete improvement and successfully removed the catheters. This report suggests that PTBD is a viable and safe treatment option for obstructive jaundice in very young infants.
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Affiliation(s)
- Sung Hui Chang
- Department of Pediatrics, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Seung Moon Joo
- Department of Radiology, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Choon Sik Yoon
- Department of Radiology, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Kwang Hun Lee
- Department of Radiology, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Soon Min Lee
- Department of Pediatrics, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea.
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Yang CH, Chen CY, Chou YY, Chiu HC, Tsai WL, Shiesh SC. Bile acid profiles in neonatal intrahepatic cholestasis caused by citrin deficiency. Clin Chim Acta 2017; 475:28-35. [DOI: 10.1016/j.cca.2017.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 09/28/2017] [Accepted: 10/03/2017] [Indexed: 01/29/2023]
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Abstract
Due to a peculiar age-dependent increased susceptibility, neonatal cholestasis affects the liver of approximately 1 in every 2500 term infants. A high index of suspicion is the key to an early diagnosis, and to implement timely, often life-saving treatments. Even when specific treatment is not available or curative, prompt medical management and optimization of nutrition are of paramount importance to survival and avoidance of complications. Areas covered: The present article will prominently focus on a series of newer diagnostic and therapeutic options of cholestasis in neonates and infants blended with consolidated established paradigms. The overview of strategies for the management reported here is based on a systematic literature search published in English using accessible databases (PubMed, MEDLINE) with the keywords biliary atresia, choleretics and neonatal cholestasis. References lists from retrieved articles were also reviewed. Expert commentary: A large number of uncommon and rare hepatobiliary disorders may present with cholestasis during the neonatal and infantile period. Potentially life-saving disease-specific pharmacological and surgical therapeutic approaches are currently available. Advances in hepatobiliary transport mechanisms have started clarifying fundamental aspects of inherited and acquired cholestasis, laying the foundation for the development of possibly more effective specific therapies.
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Affiliation(s)
- Andrea Catzola
- a Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Pediatrics Section , University of Salerno , Salerno , Italy
| | - Pietro Vajro
- a Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Pediatrics Section , University of Salerno , Salerno , Italy
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Hopkins PC, Yazigi N, Nylund CM. Incidence of Biliary Atresia and Timing of Hepatoportoenterostomy in the United States. J Pediatr 2017; 187:253-257. [PMID: 28746031 DOI: 10.1016/j.jpeds.2017.05.006] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 04/10/2017] [Accepted: 05/02/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the incidence, trends, seasonality, and age at the time of hepatoportoenterostomy (Kasai procedure) for biliary atresia in the US. STUDY DESIGN The triennial Health Cost and Utilization Project-Kids' Inpatient Database for 1997-2012 was used to perform a retrospective analysis of biliary atresia in the US. Infants aged <1 year of age with a diagnosis of biliary atresia who underwent a Kasai procedure were included. Nationwide infant population data were used to calculate incidence and evaluate trends. Age at the time of the Kasai procedure and the seasonality of biliary atresia were evaluated as well. RESULTS The incidence of biliary atresia in the US was 4.47 per 100 000 and was higher in females (risk ratio [RR], 1.43; 95% CI, 1.27-1.62), Asian/Pacific Islanders (RR, 1.89; 95% CI, 1.44-2.47), and blacks (RR, 1.30; 95% CI, 1.06-1.58) compared with whites. The incidence of biliary atresia increased by an average of 7.9% per year from 1997 to 2012 (P <.001). The median age at the time of the Kasai procedure was 63 days, with no improvement over the study period (P = .64). There was no evidence of seasonality (P = .69). CONCLUSION The incidence of biliary atresia has increased over the past 15 years, with the median age at the time of the Kasai procedure now outside the optimal window. Implementation of systematic screening measures for biliary atresia in the US are needed.
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Affiliation(s)
- Perri C Hopkins
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD.
| | - Nada Yazigi
- MedStar Georgetown Transplant Institute, Washington, DC
| | - Cade M Nylund
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD
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Schady DA, Finegold MJ. Contemporary Evaluation of the Pediatric Liver Biopsy. Gastroenterol Clin North Am 2017; 46:233-252. [PMID: 28506363 DOI: 10.1016/j.gtc.2017.01.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Liver disease in the neonate, infant, child, and adolescent may manifest differently depending on the type of disorder. These disorders show marked overlap clinically and on light microscopy. Histology and ultrastructural examination are used in tandem for the diagnosis of most disorders. A final diagnosis or interpretation of the pediatric liver biopsy depends on appropriate and adequate clinical history, laboratory test results, biochemical assays, and molecular analyses, as indicated by the light microscopic and ultrastructural examination.
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Affiliation(s)
- Deborah A Schady
- Department of Pathology and Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Milton J Finegold
- Department of Pathology and Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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Lu CT, Shi QP, Li ZJ, Li J, Feng L. Blood glucose and insulin and correlation of SLC25A13 mutations with biochemical changes in NICCD patients. Exp Biol Med (Maywood) 2017; 242:1271-1278. [PMID: 28516797 DOI: 10.1177/1535370217710918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Neonatal intrahepatic cholestasis caused by citrin deficiency (NICCD) is a hereditary metabolic disease arising from biallelic mutations of SLC25A13. This study aimed to explore the characteristics of fasting blood glucose (FBG), fasting insulin (FINS) and C-peptide (C-P) levels in NICCD infants, analyze their SLC25A13 genetic mutations and further discuss the correlation between SLC25A13 genetic mutations and biochemical changes. Seventy-two cases of infants with cholestasis disease were gathered. Among them, 36 cases with NICCD diagnosis were case group. Meanwhile, 36 cases with unknown etiology but excluded NICCD were control group. FBG, FINS, C-P, ALT, AST, GGT, ALP, TG, HDL-C, LDL-C and Non-HDL-C were collected from all subjects, and DNA was extracted from venous blood for SLC25A13 mutations detection. The incidence of hypoglycemia was 3% in NICCD group. There were no significant statistical difference of FBG, FINS and C-P between NICCD and INC groups ( P > 0.05). ALT, LDL-C and Non-HDL-C levels in NICCD group were lower than the INC group, while SLC25A13 mutations were associated with the level of GGT ( P < 0.05). Ten different SLC25A13 genetic mutations were detected, among which, 851del4, IVS16ins3kb, IVS6+5 G > A and 1638ins23 mutations made up 82% of all mutations. The incidence of hypoglycemia may be higher in small gestational age infants with NICCD. Low LDL-C may be one of the characteristics of dyslipidemia in NICCD infants. There was a correlation between SLC25A13 gene mutations distribution and the GGT level, but the meaning of this finding remains to be further in-depth study. Impact statement This study aims to compare FBG, FINS, C-P, other biochemical and clinical manifestations between NICCD and non-NICCD infants, and discuss differential diagnosis of NICCD and INC beyond the genetic analysis. And investigate the correlation between SLC25A13 genetic mutations and biochemical changes. This work presented that incidence of hypoglycemia may be higher in small gestational age infants with NICCD. Low LDL-C may be one of the characteristics of dyslipidemia in NICCD infants. There was a correlation between SLC25A13 gene mutations distribution and the GGT level.
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Affiliation(s)
- Chun-Ting Lu
- 1 Science and Education Office, Jinan University, First Affiliated Hospital, Guangzhou 510630, China.,2 Department of Endocrinology and Metabolism, Jinan University, First Affiliated Hospital, Guangzhou 510630, China
| | - Qi-Ping Shi
- 2 Department of Endocrinology and Metabolism, Jinan University, First Affiliated Hospital, Guangzhou 510630, China
| | - Ze-Jian Li
- 3 Medical Centre of Stomatology, Jinan University, First Affiliated Hospital, Guangzhou 510630, China
| | - Jiong Li
- 4 Department of Anatomy, Medical School, Jinan University, Guangzhou 510630, China
| | - Lie Feng
- 2 Department of Endocrinology and Metabolism, Jinan University, First Affiliated Hospital, Guangzhou 510630, China
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Hendriksz CJ, Anheim M, Bauer P, Bonnot O, Chakrapani A, Corvol JC, de Koning TJ, Degtyareva A, Dionisi-Vici C, Doss S, Duning T, Giunti P, Iodice R, Johnston T, Kelly D, Klünemann HH, Lorenzl S, Padovani A, Pocovi M, Synofzik M, Terblanche A, Then Bergh F, Topçu M, Tranchant C, Walterfang M, Velten C, Kolb SA. The hidden Niemann-Pick type C patient: clinical niches for a rare inherited metabolic disease. Curr Med Res Opin 2017; 33:877-890. [PMID: 28276873 DOI: 10.1080/03007995.2017.1294054] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 01/31/2017] [Accepted: 02/08/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND Niemann-Pick disease type C (NP-C) is a rare, inherited neurodegenerative disease of impaired intracellular lipid trafficking. Clinical symptoms are highly heterogeneous, including neurological, visceral, or psychiatric manifestations. The incidence of NP-C is under-estimated due to under-recognition or misdiagnosis across a wide range of medical fields. New screening and diagnostic methods provide an opportunity to improve detection of unrecognized cases in clinical sub-populations associated with a higher risk of NP-C. Patients in these at-risk groups ("clinical niches") have symptoms that are potentially related to NP-C, but go unrecognized due to other, more prevalent clinical features, and lack of awareness regarding underlying metabolic causes. METHODS Twelve potential clinical niches identified by clinical experts were evaluated based on a comprehensive, non-systematic review of literature published to date. Relevant publications were identified by targeted literature searches of EMBASE and PubMed using key search terms specific to each niche. Articles published in English or other European languages up to 2016 were included. FINDINGS Several niches were found to be relevant based on available data: movement disorders (early-onset ataxia and dystonia), organic psychosis, early-onset cholestasis/(hepato)splenomegaly, cases with relevant antenatal findings or fetal abnormalities, and patients affected by family history, consanguinity, and endogamy. Potentially relevant niches requiring further supportive data included: early-onset cognitive decline, frontotemporal dementia, parkinsonism, and chronic inflammatory CNS disease. There was relatively weak evidence to suggest amyotrophic lateral sclerosis or progressive supranuclear gaze palsy as potential niches. CONCLUSIONS Several clinical niches have been identified that harbor patients at increased risk of NP-C.
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Affiliation(s)
- Christian J Hendriksz
- a Salford Royal NHS Foundation Trust , Manchester , UK
- b University of Pretoria , Pretoria , South Africa
| | - Mathieu Anheim
- c University of Strasbourg , Hautepierre Hospital , Strasbourg , France
| | - Peter Bauer
- d Institute of Medical Genetics and Applied Genomics, Tübingen University , Tübingen, Germany
- e CENTOGENE AG , Rostock , Germany
| | | | | | - Jean-Christophe Corvol
- h Sorbonne University , UPMC and Hôpital Pitié-Salpêtrière, Department of Nervous System Diseases , Paris , France
| | | | - Anna Degtyareva
- j Federal State Budget Institution, Research Center for Obstetrics , Gynecology and Perinatology , Moscow , Russia
| | | | - Sarah Doss
- l Charite University Medicine Berlin , Department of Neurology , Berlin , Germany
| | | | - Paola Giunti
- n University College London, Institute of Neurology , London , UK
| | - Rosa Iodice
- o University Federico II Naples , Naples , Italy
| | | | | | - Hans-Hermann Klünemann
- r University Clinic for Psychiatry and Psychotherapy, Regensburg University , Regensburg , Germany
| | - Stefan Lorenzl
- s Ludwig Maximillian University , Munich , Germany
- t Paracelus Medical University , Salzburg , Austria
| | - Alessandro Padovani
- u Neurology Unit, Department of Clinical and Experimental Sciences , University of Brescia , Brescia , Italy
| | | | - Matthis Synofzik
- w Department of Neurodegenerative Diseases , Hertie Institute for Clinical Brain Research , Tübingen, Germany
- x German Center for Neurodegenerative Diseases (DZNE) , Tübingen, Germany
| | | | | | - Meral Topçu
- z Hacettepe University Children's Hospital , Ankara , Turkey
| | | | | | | | - Stefan A Kolb
- ac Actelion Pharmaceuticals Ltd , Allschwil , Switzerland
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Stephens MC, Boardman LA, Lazaridis KN. Individualized Medicine in Gastroenterology and Hepatology. Mayo Clin Proc 2017; 92:810-825. [PMID: 28473040 DOI: 10.1016/j.mayocp.2017.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 02/23/2017] [Accepted: 03/02/2017] [Indexed: 02/08/2023]
Abstract
After the completion of the Human Genome Project, there has been an acceleration in methodologies on sequencing nucleic acids (DNA and RNA) at a high precision and with ever-decreasing turnaround time and cost. Collectively, these approaches are termed next-generation sequencing and are already affecting the transformation of medical practice. In this symposium article, we highlight the current knowledge of the genetics of selected gastrointestinal tract and liver diseases, namely, inflammatory bowel disease, hereditary cholestatic liver disease, and familial colon cancer syndromes. In addition, we provide a stepwise approach to use next-generation sequencing methodologies for clinical practice with the goal to improve the diagnosis as well as management of and/or therapy of the chosen digestive diseases. This early experience of applying next-generation sequencing in the practice of gastroenterology and hepatology will delineate future best practices in the field, ultimately for the benefit of our patients.
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Affiliation(s)
- Michael C Stephens
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, MN
| | - Lisa A Boardman
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, MN
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Guideline for the Evaluation of Cholestatic Jaundice in Infants: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2017; 64:154-168. [PMID: 27429428 DOI: 10.1097/mpg.0000000000001334] [Citation(s) in RCA: 274] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cholestatic jaundice in infancy affects approximately 1 in every 2500 term infants and is infrequently recognized by primary providers in the setting of physiologic jaundice. Cholestatic jaundice is always pathologic and indicates hepatobiliary dysfunction. Early detection by the primary care physician and timely referrals to the pediatric gastroenterologist/hepatologist are important contributors to optimal treatment and prognosis. The most common causes of cholestatic jaundice in the first months of life are biliary atresia (25%-40%) followed by an expanding list of monogenic disorders (25%), along with many unknown or multifactorial (eg, parenteral nutrition-related) causes, each of which may have time-sensitive and distinct treatment plans. Thus, these guidelines can have an essential role for the evaluation of neonatal cholestasis to optimize care. The recommendations from this clinical practice guideline are based upon review and analysis of published literature and the combined experience of the authors. The committee recommends that any infant noted to be jaundiced after 2 weeks of age be evaluated for cholestasis with measurement of total and direct serum bilirubin, and that an elevated serum direct bilirubin level (direct bilirubin levels >1.0 mg/dL or >17 μmol/L) warrants timely consideration for evaluation and referral to a pediatric gastroenterologist or hepatologist. Of note, current differential diagnostic plans now incorporate consideration of modern broad-based next-generation DNA sequencing technologies in the proper clinical context. These recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the care of all infants with cholestasis. Broad implementation of these recommendations is expected to reduce the time to the diagnosis of pediatric liver diseases, including biliary atresia, leading to improved outcomes.
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Santetti D, de Albuquerque Wilasco MI, Dornelles CTL, Werlang ICR, Fontella FU, Kieling CO, dos Santos JL, Vieira SMG, Goldani HAS. Serum proinflammatory cytokines and nutritional status in pediatric chronic liver disease. World J Gastroenterol 2015; 21:8927-8934. [PMID: 26269683 PMCID: PMC4528036 DOI: 10.3748/wjg.v21.i29.8927] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 01/06/2015] [Accepted: 02/13/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the nutritional status and its association with proinflammatory cytokines in children with chronic liver disease.
METHODS: We performed a cross-sectional study with 43 children and adolescents, aged 0 to 17 years, diagnosed with chronic liver disease. All patients regularly attended the Pediatric Hepatology Unit and were under nutritional follow up. The exclusion criteria were fever from any etiology at the time of enrollment, inborn errors of the metabolism and any chronic illness. The severity of liver disease was assessed by Child-Pugh, Model for End-stage Liver Disease (MELD) and Pediatric End Stage Liver Disease (PELD) scores. Anthropometric parameters were height/age, body mass index/age and triceps skinfold/age according to World Health Organization standards. The cutoff points for nutritional status were risk of malnutrition (Z-score < -1.00) and malnutrition (Z-score < -2.00). Interleukin-1β (IL-1β), IL-6 and tumor necrosis factor-α levels were assessed by commercial ELISA kits. For multivariate analysis, linear regression was applied to assess the association between cytokine levels, disease severity and nutritional status.
RESULTS: The median (25th-75th centile) age of the study population was 60 (17-116)-mo-old, and 53.5% were female. Biliary atresia was the main cause of chronic liver disease (72%). With respect to Child-Pugh score, cirrhotic patients were distributed as follows: 57.1% Child-Pugh A, a mild presentation of the disease, 34.3% Child-Pugh B, a moderate stage of cirrhosis and 8.6% Child-Pugh C, were considered severe cases. PELD and MELD scores were only above the cutoff point in 5 cases. IL-6 values were increased in patients at nutritional risk (34.9%) compared with those who were well-nourished [7.12 (0.58-34.23) pg/mL vs 1.63 (0.53-3.43) pg/mL; P = 0.02], correlating inversely with triceps skinfold-for-age z-score (rs = -0.61; P < 0.001). IL-6 levels were associated with liver disease severity assessed by Child-Pugh score (P = 0.001). This association remained significant after adjusting for nutritional status in a linear regression model.
CONCLUSION: High IL-6 levels were found in children with chronic liver disease at nutritional risk. Inflammatory activity may be related to nutritional status deterioration in these patients.
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Using volume index and lateral hepatic angle to differentiate biliary atresia from TPN-associated cholestasis. J Pediatr Gastroenterol Nutr 2014; 59:403-8. [PMID: 24821537 DOI: 10.1097/mpg.0000000000000433] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Differential diagnosis between biliary atresia (BA) and total parenteral nutrition-associated cholestasis (TPN-AC) and early treatment for cholestatic infants are challenges for evaluating neonatal or infantile cholestasis. The aim of our retrospective study was to apply noninvasive indices of magnetic resonance images to differentiate BA from TPN-AC. METHODS A total of 44 patients diagnosed as having BA (n = 30) or TPN-AC (n = 14) were included in the present retrospective study and underwent abdominal magnetic resonance imaging to evaluate the possibility of BA. The left lateral hepatic angle was determined from the coronal image of the left portal vein and portal vein of segment II. Adjusted volume indices of the right hepatic lobe (AVIR) and left lateral segment (AVILL) were calculated as the product of 3 diameters (centimeters) divided by each patient's body weight. RESULTS The left lateral hepatic angles of patients with BA (74° ± 21°) were significantly larger than for patients with TPN-AC (33° ± 9°) and controls (36° ± 5°, P < 0.05). AVILL of the BA (0.037 ± 0.012 cm/g) and TPN-AC groups (0.042 ± 0.030 cm/g) were not significantly different (P = 0.61) but were significantly larger than for controls (0.020 ± 0.011 cm/g) (P < 0.05). The right hepatic lobe to left lateral hepatic segment ratio (RLR) of patients with BA was significantly (P < 0.05) smaller (1.61 ± 0.58) than for patients with TPN-AC (3.08 ± 2.43) and controls (2.98 ± 0.92). Patients with BA could have relative sparing and selective enlargement of the left lateral liver with a resultant lobar difference and blunt left lateral hepatic angle. CONCLUSIONS Noninvasive indices of lobar difference and left lateral hepatic angle help differentiate patients with BA from those with TPN-AC.
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Levit OL, Calkins KL, Gibson LC, Kelley-Quon L, Robinson DT, Elashoff DA, Grogan TR, Li N, Bizzarro MJ, Ehrenkranz RA. Low-Dose Intravenous Soybean Oil Emulsion for Prevention of Cholestasis in Preterm Neonates. JPEN J Parenter Enteral Nutr 2014; 40:374-82. [PMID: 24963025 DOI: 10.1177/0148607114540005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/16/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Premature infants depend on intravenous fat emulsions to supply essential fatty acids and calories. The dose of soybean-based intravenous fat emulsions (S-IFE) has been associated with parenteral nutrition (PN)-associated liver disease. This study's purpose was to determine if low-dose S-IFE is a safe and effective preventive strategy for cholestasis in preterm neonates. MATERIALS AND METHODS This is a multicenter randomized controlled trial in infants with a gestational age (GA) ≤29 weeks. Patients <48 hours of life were randomized to receive a low (1 g/kg/d) or control dose (approximately 3 g/kg/d) of S-IFE. The primary outcome was cholestasis, defined as a direct bilirubin ≥15% of the total bilirubin at 28 days of life (DOL) or full enteral feeds, whichever was later, after 14 days of PN. Secondary outcomes included growth, length of hospital stay, death, and major neonatal morbidities. RESULTS In total, 136 neonates (67 and 69 in the low and control groups, respectively) were enrolled. Baseline characteristics were similar for the 2 groups. When the low group was compared with the control group, there was no difference in the primary outcome (69% vs 63%; 95% confidence interval, -0.1 to 0.22; P = .45). While the low group received less S-IFE and total calories over time compared with the control group (P < .001 and P = .03, respectively), weight, length, and head circumference at 28 DOL, discharge, and over time were not different (P > .2 for all). CONCLUSION Compared with the control dose, low-dose S-IFE was not associated with a reduction in cholestasis or growth.
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Affiliation(s)
- Orly L Levit
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Kara L Calkins
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California
| | - L Caroline Gibson
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Lorraine Kelley-Quon
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Daniel T Robinson
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - David A Elashoff
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Tristan R Grogan
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Ning Li
- Department of Biomathematics, University of California, Los Angeles, California
| | - Matthew J Bizzarro
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Richard A Ehrenkranz
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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Thibault M, McMahon J, Faubert G, Charbonneau J, Malo J, Ferreira E, Mohamed I. Parenteral nutrition-associated liver disease: a retrospective study of ursodeoxycholic Acid use in neonates. J Pediatr Pharmacol Ther 2014; 19:42-8. [PMID: 24782691 DOI: 10.5863/1551-6776-19.1.42] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To verify the effect of ursodeoxycholic acid (UDCA) on the duration of neonatal parenteral nutrition-associated liver disease. METHODS Retrospective cohort study of neonates in intensive care between 2004 and 2007 presenting with parenteral nutrition-associated liver disease. RESULTS Of 118 eligible infants, 64 received UDCA. Cholestasis lasted longer in the UDCA group (79 vs. 50 days, p=0.001). However, treatment was delayed for a median of 24 days after cholestasis onset. Multivariate Cox regression analysis showed no association between UDCA and cholestasis duration. The rate of decline of conjugated bilirubin was greater in treated patients (median 0.084 mg/dL/day vs. 0.60 mg/dL/day; p=0.009) and weight gain was greater (22.8 vs. 17.7 g/kg/day, p=0.010). CONCLUSIONS UDCA therapy was not associated with the duration of parenteral nutrition-associated liver disease. A delay in treatment initiation might explain this result. UDCA therapy was associated with a faster decline of conjugated bilirubin and greater weight gain.
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Affiliation(s)
- Maxime Thibault
- Department of Pharmacy, CHU Sainte-Justine, Montreal, Canada
| | - Jessica McMahon
- Department of Pharmacy, CHU Sainte-Justine, Montreal, Canada
| | | | | | - Josianne Malo
- Department of Pharmacy, CHU Sainte-Justine, Montreal, Canada
| | - Ema Ferreira
- Department of Pharmacy, CHU Sainte-Justine, Montreal, Canada ; Faculty of Pharmacy, University of Montreal, Montreal, Canada
| | - Ibrahim Mohamed
- Faculty of Medicine, University of Montreal, Montreal, Canada
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Management of neonatal cholestasis: Consensus statement of the pediatric gastroenterology chapter of Indian academy of pediatrics. Indian Pediatr 2014; 51:203-10. [DOI: 10.1007/s13312-014-0375-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Cofer ZC, Matthews RP. Zebrafish Models of Biliary Atresia and Other Infantile Cholestatic Diseases. CURRENT PATHOBIOLOGY REPORTS 2014. [DOI: 10.1007/s40139-014-0040-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Parenteral nutrition-induced cholestasis in neonates: where does the problem lie? Gastroenterol Res Pract 2013; 2013:163632. [PMID: 24348529 PMCID: PMC3847965 DOI: 10.1155/2013/163632] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 10/05/2013] [Indexed: 11/17/2022] Open
Abstract
Background. Parenteral nutrition (PN) is an effective method of nourishing the neonate who is unable to receive full enteral feeds. Cholestasis can be a complication of PN and can lead to severe liver damage. Aim. We describe our patient population and determine risk factors for developing PN cholestasis. Methods. Retrospective chart review of newborns admitted from January 2006 to May 2011 to the Neonatal Intensive Care Unit at our institution and received PN >14 days. Cholestasis was defined as serum conjugated bilirubin >50 μ mol/L. Results. Eighty-seven newborns were included; 18 (20.7%) developed PN cholestasis. The most frequent surgical condition for both groups was gastroschisis (8/87; 9.2%). No significant differences were found between the cholestasis and control groups for the following parameters: birth weight, gestational age, intrauterine growth restriction, Apgar scores, and day of life at initiation of enteral feeds. Duration of PN in days and dosage of carbohydrates in g/kg/day were significantly higher in the cholestasis group than the control group. Conclusion. PN-related cholestasis presented in one-fifth of neonates receiving PN for more than two weeks. Longer duration of PN and higher dosage of carbohydrates were independent risk factors for the development of PN cholestasis in this population.
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Cui S, Leyva-Vega M, Tsai EA, Eauclaire SF, Glessner JT, Hakonarson H, Devoto M, Haber BA, Spinner NB, Matthews RP. Evidence from human and zebrafish that GPC1 is a biliary atresia susceptibility gene. Gastroenterology 2013; 144:1107-1115.e3. [PMID: 23336978 PMCID: PMC3736559 DOI: 10.1053/j.gastro.2013.01.022] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 01/03/2013] [Accepted: 01/07/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Biliary atresia (BA) is a progressive fibroinflammatory disorder of infants involving the extrahepatic and intrahepatic biliary tree. Its etiology is unclear but is believed to involve exposure of a genetically susceptible individual to certain environmental factors. BA occurs exclusively in the neonatal liver, so variants of genes expressed during hepatobiliary development could affect susceptibility. Genome-wide association studies previously identified a potential region of interest at 2q37. We continued these studies to narrow the region and identify BA susceptibility genes. METHODS We searched for copy number variants that were increased among patients with BA (n = 61) compared with healthy individuals (controls; n = 5088). After identifying a candidate gene, we investigated expression patterns of orthologues in zebrafish liver and the effects of reducing expression, with morpholino antisense oligonucleotides, on biliary development, gene expression, and signal transduction. RESULTS We observed a statistically significant increase in deletions at 2q37.3 in patients with BA that resulted in deletion of one copy of GPC1, which encodes glypican 1, a heparan sulfate proteoglycan that regulates Hedgehog signaling and inflammation. Knockdown of gpc1 in zebrafish led to developmental biliary defects. Exposure of the gpc1 morphants to cyclopamine, a Hedgehog antagonist, partially rescued the gpc1-knockdown phenotype. Injection of zebrafish with recombinant Sonic Hedgehog led to biliary defects similar to those of the gpc1 morphants. Liver samples from patients with BA had reduced levels of apical GPC1 in cholangiocytes compared with samples from controls. CONCLUSIONS Based on genetic analysis of patients with BA and zebrafish, GPC1 appears to be a BA susceptibility gene. These findings also support a role for Hedgehog signaling in the pathogenesis of BA.
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Affiliation(s)
- Shuang Cui
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa Leyva-Vega
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ellen A. Tsai
- Department of Pathology and Laboratory Medicine, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Genomics and Computational Biology Graduate Group, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven F. Eauclaire
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph T. Glessner
- Center for Applied Genomics, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hakon Hakonarson
- Center for Applied Genomics, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Pediatrics, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Genetics, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marcella Devoto
- Department of Pediatrics, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Biostatistics and Epidemiology, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Molecular Medicine, University of Rome La Sapienza, Rome, Italy
| | - Barbara A. Haber
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Pediatrics, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nancy B. Spinner
- Department of Pathology and Laboratory Medicine, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Randolph P. Matthews
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Pediatrics, The Children’s Hospital of Philadelphia Research Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
Cholestatic jaundice is a common presenting feature of neonatal hepatobiliary and metabolic dysfunction. Any infant who remains jaundiced beyond age 2 to 3 weeks should have the serum bilirubin level fractionated into a conjugated (direct) and unconjugated (indirect) portion. Conjugated hyperbilirubinemia is never physiologic or normal. The differential diagnosis of cholestasis is extensive, and a step-wise approach based on the initial history and physical examination is useful to rapidly identify the underlying etiology. Early recognition of neonatal cholestasis is essential to ensure timely treatment and optimal prognosis. Even when specific treatment is not available, infants who have cholestasis benefit from early medical management and optimization of nutrition. Future studies are necessary to determine the most reliable and cost-effective method of universal screening for neonatal cholestasis.
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Affiliation(s)
- Amy G Feldman
- Fellow in Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, and Digestive Health Institute, Children's Hospital Colorado, CO
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Lu Y, Zhang Z, Xiong X, Wang X, Li J, Shi G, Yang J, Zhang X, Zhang H, Hong J, Xia X, Ning G, Li X. Glucocorticoids promote hepatic cholestasis in mice by inhibiting the transcriptional activity of the farnesoid X receptor. Gastroenterology 2012; 143:1630-1640.e8. [PMID: 22922423 DOI: 10.1053/j.gastro.2012.08.029] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 08/12/2012] [Accepted: 08/16/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Glucocorticoids have potent anti-inflammatory effects, but also can cause insulin resistance, osteoporosis, and muscle wasting, preventing their long-term use. Glucocorticoids also have been associated with the development of hepatic cholestasis and gallstone disease, but little is known about their pathogenic mechanisms. METHODS We analyzed levels of bile acids (BAs) and glucocorticoids in serum samples from patients with Cushing disease and obese individuals (body mass index, >30). C57BL/6 mice were injected with dexamethasone and db/db obese mice were injected with glucocorticoid receptor (GR) antagonists or small hairpin RNAs. We analyzed farnesoid X receptor (FXR) signaling in HepG2 cells and cells from mice using immunoprecipitation, luciferase reporter, and glutathione-s-transferase and chromatin immunoprecipitation assays. We analyzed BA metabolism in FXR-/- mice and mice with reduced levels of the transcription factor C-terminal binding protein (CtBP). RESULTS Serum levels of BAs were higher in patients with Cushing disease or obesity than in individuals with normal levels of glucocorticoids. Administration of dexamethasone promoted cholestasis and overproduction of BAs in C57BL/6 mice, but not in FXR-/- mice. GR antagonists, or injection of an adenoviral small hairpin RNA against GR, reduced features of hepatic cholestasis in db/db mice. The GR interacted with FXR to reduce its transcriptional activity by recruiting CtBP co-repressor complexes. Mice with reduced levels of CtBP were resistant to induction of hepatic cholestasis by dexamethasone. CONCLUSIONS Glucocorticoids promote hepatic cholestasis in mice by recruiting CtBP co-repressor complexes to FXR and thereby blocking the transcriptional activity.
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Affiliation(s)
- Yan Lu
- Shanghai Institute of Endocrinology and Metabolism, Department of Endocrine and Metabolic Diseases, Shanghai Clinical Center for Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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41
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Arnell H, Fischler B. Population-based study of incidence and clinical outcome of neonatal cholestasis in patients with Down syndrome. J Pediatr 2012; 161:899-902. [PMID: 22658787 DOI: 10.1016/j.jpeds.2012.04.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 02/14/2012] [Accepted: 04/18/2012] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To study the incidence and outcome of Down syndrome-associated neonatal cholestasis in a population-based cohort. STUDY DESIGN This retrospective study included all neonates diagnosed with Down syndrome born between January 2005 and September 2011 in the County of Stockholm, Sweden. Clinical and biochemical data related to cholestasis, early gastrointestinal (GI) involvement, congenital heart defects (CHD), and bone marrow disease were obtained from the computer-based hospital chart system. RESULTS A total of 206 newborns with Down syndrome were identified, for an incidence of 1 in 880 newborns. Prevalences of other diseases in these newborns included 47% for CHD, 11.2% for GI involvement, 3.9% for neonatal cholestasis, and 3.4% for bone marrow disease. Neonatal cholestasis was more common in the newborns with GI involvement (3 of 23 vs 5 of 183 of those without GI involvement; P = .047), CHD (8 of 96 vs 0 of 110 of those without CHD; P = .0019), and bone marrow disease (3 of 7 vs 5 of 199 of those without bone marrow disease; P = .0013). Cholestasis was severe in 3 patients (all of whom had bone marrow disease, with liver failure and early death in 2), and transient in 5 patients. CONCLUSION Neonatal cholestasis occurs in a significant percentage of patients with Down syndrome and is always associated with involvement of other organs. The outcome is variable, being most severe in newborns with the combination of neonatal cholestasis and bone marrow disease.
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Affiliation(s)
- Henrik Arnell
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Karolinska University Hospital and Division of Pediatrics, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
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Treepongkaruna S, Jitraruch S, Kodcharin P, Charoenpipop D, Suwannarat P, Pienvichit P, Kobayashi K, Wattanasirichaigoon D. Neonatal intrahepatic cholestasis caused by citrin deficiency: prevalence and SLC25A13 mutations among Thai infants. BMC Gastroenterol 2012; 12:141. [PMID: 23067347 PMCID: PMC3483206 DOI: 10.1186/1471-230x-12-141] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 10/08/2012] [Indexed: 01/13/2023] Open
Abstract
Background The most common causes of cholestatic jaundice are biliary atresia and idiopathic neonatal hepatitis (INH). Specific disorders underlying INH, such as various infectious and metabolic causes, including neonatal intrahepatic cholestasis caused by citrin deficiency (NICCD) especially, in East Asian populations are increasingly being identified. Since most NICCD infants recovered from liver disease by 1 year of age, they often are misdiagnosed with INH, leading to difficulty in determining the true prevalence of NICCD. Mutation(s) of human SLC25A13 gene encoding a mitochondrial aspartate/glutamate carrier isoform 2 (AGC2), can lead to AGC2 deficiency, resulting in NICCD and an adult-onset fatal disease namely citrullinemia type II (CTLN2). To study the prevalence of NICCD and SLC25A13 mutations in Thai infants, and to compare manifestations of NICCD and non-NICCD, infants with idiopathic cholestatic jaundice or INH were enrolled. Clinical and biochemical data were reviewed. Urine organic acid and plasma amino acids profiles were analyzed. PCR-sequencing of all 18 exons of SLC25A13 and gap PCR for the mutations IVS16ins3kb and Ex16+74_IVS17-32del516 were performed. mRNA were analyzed in selected cases with possible splicing error. Results Five out of 39 (12.8%) unrelated infants enrolled in the study were found to have NICCD, of which three had homozygous 851del4 (GTATdel) and two compound heterozygous 851del4/IVS16ins3kb and 851del4/1638ins23, respectively. Two missense mutations (p.M1? and p.R605Q) of unknown functional significance were identified. At the initial presentation, NICCD patients had higher levels of alkaline phosphatase (ALP) and alpha-fetoprotein (AFP) and lower level of alanine aminotransferase (ALT) than those in non-NICCD patients (p< 0.05). NICCD patients showed higher citrulline level and threonine/serine ratio than non-NICCD infants (p< 0.05). Fatty liver was found in 2 NICCD patients. Jaundice resolved in all NICCD and in 87.5% of non-NICCD infants at the median age of 9.5 and 4.0 months, respectively. Conclusion NICCD should be considered in infants with idiopathic cholestasis. The preliminary estimated prevalence of NICCD was calculated to be 1/48,228 with carrier rate of 1/110 among Thai infants. However, this number may be underestimated and required further analysis with mutation screening in larger control population to establish the true prevalence of NICCD and AGC2 deficiency.
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Affiliation(s)
- Suporn Treepongkaruna
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
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Braslavsky D, Keselman A, Galoppo M, Lezama C, Chiesa A, Galoppo C, Bergadá I. Neonatal cholestasis in congenital pituitary hormone deficiency and isolated hypocortisolism: characterization of liver dysfunction and follow-up. ACTA ACUST UNITED AC 2012; 55:622-7. [PMID: 22218445 DOI: 10.1590/s0004-27302011000800017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 10/17/2011] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Neonatal cholestasis due to endocrine diseases is infrequent and poorly recognized. Referral to the pediatric endocrinologist is delayed. OBJECTIVE We characterized cholestasis in infants with congenital pituitary hormone deficiencies (CPHD), and its resolution after hormone replacement therapy (HRT). SUBJECTS AND METHODS Sixteen patients (12 males) were included; eleven with CPHD, and five with isolated central hypocortisolism. RESULTS Onset of cholestasis occurred at a median age of 18 days of life (range 2-120). Ten and nine patients had elevated transaminases and γGT, respectively. Referral to the endocrinologist occurred at 32 days (range 1 - 72). Remission of cholestasis occurred at a median age of 65 days, whereas liver enzymes occurred at 90 days. In our cohort isolated, hypocortisolism was a transient disorder. CONCLUSION Cholestasis due to hormonal deficiencies completely resolved upon introduction of HRT. Isolated hypocortisolism may be a transient cause of cholestasis that needs to be re-evaluated after remission of cholestasis.
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Affiliation(s)
- Débora Braslavsky
- División de Endocrinología, Centro de Investigaciones Endocrinológicas, Buenos Aires, Argentina.
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Harpavat S, Finegold MJ, Karpen SJ. Patients with biliary atresia have elevated direct/conjugated bilirubin levels shortly after birth. Pediatrics 2011; 128:e1428-33. [PMID: 22106076 PMCID: PMC3387898 DOI: 10.1542/peds.2011-1869] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Healthy infants are thought to acquire biliary atresia (BA) in the first weeks of life. Because those diagnosed earlier have better outcomes, we were interested in determining the earliest time BA could be detected. We started by examining the immediate postnatal period, hypothesizing that newborns would not yet have acquired disease and still have normal direct/conjugated bilirubin (DB/CB) levels. PATIENTS AND METHODS Newborn DB/CB levels were obtained retrospectively from birth hospitals. Subjects with BA were born between 2007 and 2010 and cared for at Texas Children's Hospital. Those with BA splenic malformation syndrome or born prematurely were excluded. Control subjects were term newborns who later never developed neonatal liver disease. RESULTS Of the 61 subjects with BA, 56% had newborn DB/CB levels measured. All DB/CB levels exceeded laboratory norms and rose over time. At 24 to 48 hours of life, subjects with BA had mean DB levels significantly higher than those of controls (1.4 ± 0.43 vs. 0.19 ± 0.075 mg/dL, P < .0001), even while their mean total bilirubin (TB) levels remained below phototherapy limits. Finally, despite the elevated DB/CB levels, the majority of patients (79%) had normal DB:TB ratios ≤ 0.2. CONCLUSIONS Patients with BA have elevated DB/CB levels shortly after birth. To detect affected infants earlier and improve outcomes, the results suggest two possibilities: (1) screen all newborns for elevated DB/CB levels, rather than just those who appear jaundiced; and then (2) follow all newborns with elevated DB/CB levels, rather than just those with DB:TB ratios >0.2.
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Affiliation(s)
- Sanjiv Harpavat
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, and
| | - Milton J. Finegold
- Department of Pathology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Saul J. Karpen
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, and
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Braslavsky D, Keselman A, Chiesa A, Bergadá I. [Diagnosis of congenital endocrinological disease in newborns with prolonged jaundice and hypoglycaemia]. An Pediatr (Barc) 2011; 76:120-6. [PMID: 22015010 DOI: 10.1016/j.anpedi.2011.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 06/13/2011] [Accepted: 08/29/2011] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The association of prolonged neonatal jaundice and hypoglycaemia may be secondary to an endocrinological disease. Pituitary insufficiency and primary adrenal insufficiency are the most likely endocrine diseases that need to be ruled out. MATERIAL AND METHODS We retrospectively analysed the clinical and laboratory characteristics of thirteen patients referred to the Hospital de Niños Ricardo Gutiérrez between years 2003 and 2008 due to prolonged neonatal jaundice and hypoglycaemia secondary to pituitary insufficiency in twelve patients, and in one secondary to primary adrenal insufficiency. RESULTS All patients had a history of neonatal hypoglycaemia. Ten patients had conjugated hyperbilirubinaemia and six also had elevated transaminases. Combined pituitary hormone deficiency was observed in the twelve hypopituitarism patients. Hormonal replacement normalised liver function and resolved the prolonged jaundice in all the patients. None of them underwent liver biopsy. Hypoglycaemia also remitted after hormonal therapy. CONCLUSIONS Prolonged or cholestatic jaundice associated with neonatal hypoglycaemia is highly likely to be due to pituitary hormone deficiency or primary adrenal insufficiency. Early diagnosis and treatment of these children reverts the prolonged jaundice and prevents morbidity and mortality due to recurrent hypoglycaemia and hormone deficiencies.
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Affiliation(s)
- D Braslavsky
- División de Endocrinología, Centro de Investigaciones Endocrinológicas, Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina.
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Abstract
BACKGROUND Extrahepatic biliary atresia results from a progressive destruction of the bile ducts by an inflammatory fibrosing process which leads ultimately to cirrhosis of biliary type. The etiology of the disorder remains unknown. The histological features include cholestasis, ductular proliferation, eventual loss of intrahepatic bile ducts, and ducts with primitive embryonic shape (ductal plate malformation). PURPOSE To examine the morphological changes of the biliary intrahepatic ducts, we aimed at investigating the cell proliferation and the diameter of the interlobular bile ducts in extrahepatic biliary atresia, and in normal liver children. METHODS Liver samples from 35 patients with biliary atresia and 10 from control normal children were used. Immunoexpression of cytokeratin 19 was evaluated and a double-staining procedure was performed with cytokeratin 8/proliferating cell nuclear antigen. The stereological measurements of the intrahepatic bile ducts diameter were evaluated by a computerized system of image analysis. RESULTS The patterns of intrahepatic cholangiopathy in biliary atresia were obstructive features (42.86%), paucity of intrahepatic bile ducts (20%), ductal plate malformation (28.57%), and ductal plate malformation associated with paucity of intrahepatic bile ducts (8.57%). The average external diameter of interlobular bile ducts in biliary atresia was smaller than that of the control infant livers. Among the four patterns of biliary atresia cholangiopathies, those associated with ductopenia showed the smallest bile duct diameter. There was a negative correlation between the bile duct to portal space ratio and the age of the child at the time of Kasai portoenterostomy. Only in biliary atresia are the bile duct cells stained with proliferating cell nuclear antigen. CONCLUSION (i) In biliary atresia, both ductular metaplasia and ductular proliferation were observed; (ii) biliary atresia associated with ductopenia showed narrowing of interlobular ducts, probably as a consequence of degeneration with atrophy and fibrosis.
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Wicklund BM. Bleeding and clotting disorders in pediatric liver disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2011; 2011:170-177. [PMID: 22160030 DOI: 10.1182/asheducation-2011.1.170] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The coagulopathy of liver disease in pediatric patients presents an unusual set of challenges. Little pediatric data have been published, so this review is based largely on adult studies. There is a precarious balance between deficiencies of clotting factors and anticoagulation factors in liver disease that result in abnormal prothrombin time (PT) and activated partial thromboplastin time (aPTT) tests that would suggest a bleeding tendency, yet the patients can form a clot and are at risk of thromboembolic disease. Attention has centered on thromboelastography and thrombin-generation assays to clarify the patient's ability to control bleeding, but these tests are not routinely available to many treating physicians.
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Affiliation(s)
- Brian M Wicklund
- Department of Hematology/Oncology, Children's Mercy Hospital, Kansas City, MO 64108, USA.
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Anakk S, Watanabe M, Ochsner SA, McKenna NJ, Finegold MJ, Moore DD. Combined deletion of Fxr and Shp in mice induces Cyp17a1 and results in juvenile onset cholestasis. J Clin Invest 2011; 121:86-95. [PMID: 21123943 PMCID: PMC3007143 DOI: 10.1172/jci42846] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 10/13/2010] [Indexed: 12/17/2022] Open
Abstract
Bile acid homeostasis is tightly regulated via a feedback loop operated by the nuclear receptors farnesoid X receptor (FXR) and small heterodimer partner (SHP). Contrary to current models, which place FXR upstream of SHP in a linear regulatory pathway, here we show that the phenotypic consequences in mice of the combined loss of both receptors are much more severe than the relatively modest impact of the loss of either Fxr or Shp alone. Fxr-/-Shp-/- mice exhibited cholestasis and liver injury as early as 3 weeks of age, and this was linked to the dysregulation of bile acid homeostatic genes, particularly cytochrome P450, family 7, subfamily a, polypeptide 1 (Cyp7a1). In addition, double-knockout mice showed misregulation of genes in the C21 steroid biosynthesis pathway, with strong induction of cytochrome P450, family 17, subfamily a, polypeptide 1 (Cyp17a1), resulting in elevated serum levels of its enzymatic product 17-hydroxyprogesterone (17-OHP). Treatment of WT mice with 17-OHP was sufficient to induce liver injury that reproduced many of the histopathological features observed in the double-knockout mice. Therefore, our data indicate a pathologic role for increased production of 17-hydroxy steroid metabolites in liver injury and suggest that Fxr-/-Shp-/- mice could provide a model for juvenile onset cholestasis.
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Affiliation(s)
- Sayeepriyadarshini Anakk
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas, USA.
Department of Internal Medicine, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan.
Department of Pathology, Baylor College of Medicine, Houston, Texas, USA
| | - Mitsuhiro Watanabe
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas, USA.
Department of Internal Medicine, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan.
Department of Pathology, Baylor College of Medicine, Houston, Texas, USA
| | - Scott A. Ochsner
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas, USA.
Department of Internal Medicine, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan.
Department of Pathology, Baylor College of Medicine, Houston, Texas, USA
| | - Neil J. McKenna
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas, USA.
Department of Internal Medicine, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan.
Department of Pathology, Baylor College of Medicine, Houston, Texas, USA
| | - Milton J. Finegold
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas, USA.
Department of Internal Medicine, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan.
Department of Pathology, Baylor College of Medicine, Houston, Texas, USA
| | - David D. Moore
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas, USA.
Department of Internal Medicine, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan.
Department of Pathology, Baylor College of Medicine, Houston, Texas, USA
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Aziz S, Wild Y, Rosenthal P, Goldstein RB. Pseudo gallbladder sign in biliary atresia--an imaging pitfall. Pediatr Radiol 2011; 41:620-6; quiz 681-2. [PMID: 21409545 PMCID: PMC3076559 DOI: 10.1007/s00247-011-2019-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 12/31/2010] [Accepted: 01/05/2011] [Indexed: 12/27/2022]
Abstract
BACKGROUND Ultrasound (US) is used to identify causes of neonatal cholestasis. We describe a potential sonographic pitfall, the "pseudo gallbladder," in biliary atresia (BA). OBJECTIVE To describe the Pseudo Gallbladder sign (PsGB sign). MATERIALS AND METHODS Sonograms/clinical records of 20 confirmed BA infants and 20 non-BA cases were reviewed retrospectively. For the BA group, preoperative sonography and surgical and pathological findings were examined. For the non-BA group, sonographic features and pathological findings were examined. The PsGB sign is defined as a fluid-filled structure, located in the expected region of the gallbladder, measuring ≤ 15 mm in length but without a well-defined or normal-appearing gallbladder wall. RESULTS A recognizable gallbladder and normal gallbladder wall were present in all non-BA infants. However, none of the BA infants had a sonographically normal gallbladder. Seventy-three percent of BA patients had a PsGB, and in 27% no gallbladder or gallbladder-like structure was detected. CONCLUSION A gallbladder-like structure in BA is common and can be misinterpreted as a normal gallbladder, delaying diagnosis and therapy. Recognition of this imaging pitfall, described here as the pseudo gallbladder sign, will help avoid this error.
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Affiliation(s)
- Seerat Aziz
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94143-0628, USA.
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Parenteral Nutrition–Associated Conjugated Hyperbilirubinemia in Hospitalized Infants. ACTA ACUST UNITED AC 2010; 110:1684-95. [DOI: 10.1016/j.jada.2010.08.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 07/08/2010] [Indexed: 11/23/2022]
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