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Alhashmi H, Chawshly E, Çelebi S. Biliary atresia-splenic malformation (BASM) syndrome: A case report. Int J Surg Case Rep 2024; 121:109937. [PMID: 38909387 PMCID: PMC11254726 DOI: 10.1016/j.ijscr.2024.109937] [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: 05/01/2024] [Revised: 06/14/2024] [Accepted: 06/21/2024] [Indexed: 06/25/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Biliary atresia (BA) is characterized by the presence of persistent cholestatic jaundice during the neonatal period. This group of patients is at higher risk for liver disease and/or portal hypertension compared with other chronic liver diseases. CASE PRESENTATION We present a newborn patient who had biliary stools early postnatally, but her gallbladder was not seen on radiological examination and was referred to our clinic. On examination, polysplenia was seen, and the inferior vena cava was not seen. The patient's stool color changed to a creamy stool without bile three weeks postnatally. The neonate was diagnosed with biliary atresia and splenic malformation (BASM) syndrome. The patient underwent a Kasai portoenterostomy in the 3rd week of age and was preoperatively diagnosed with malrotation and treated with a Ladd procedure at the same time. The patient had a postoperative stool with bile and decreased bilirubinemia with a normal defecation period. CLINICAL DISCUSSION BASM syndrome, clinically has different causes and a worse prognosis than isolated BA. The syndrome can lead to end-stage cirrhosis and liver failure if left untreated. Although timely Kasai surgery is the standard treatment for BA, the age of the patient at the time of the surgery is different depending on BA groups. CONCLUSION The most important prognostic factors for BASM syndrome are early diagnosis and treatment. Despite this, the patients need careful follow-up. Postoperative adjuvant steroid therapy may have a good impact on the outcomes.
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Affiliation(s)
- Hadeil Alhashmi
- Faculty of Medicine, Altinbas University, Bahcelievler Mahallesi, E-5 Karayolu, Kultur Sokak, No: 1, 34180 Bahcelievler, Istanbul, Turkey
| | - Esra Chawshly
- Faculty of Medicine, Altinbas University, Bahcelievler Mahallesi, E-5 Karayolu, Kultur Sokak, No: 1, 34180 Bahcelievler, Istanbul, Turkey.
| | - Süleyman Çelebi
- Faculty of Medicine, Altinbas University, Bahcelievler Mahallesi, E-5 Karayolu, Kultur Sokak, No: 1, 34180 Bahcelievler, Istanbul, Turkey.
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Loyal PK, Makhdomi K, Gitau S. A Rare Case of Biliary Atresia with Biliary Ascites on a (Hepatobiliary Iminodiacetic Acid) HIDA Scan. World J Nucl Med 2024; 23:123-125. [PMID: 38933070 PMCID: PMC11199039 DOI: 10.1055/s-0043-1764305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024] Open
Abstract
Biliary atresia is one of the most challenging conditions in pediatric surgery even when it is the only finding. Here we present a rare case of biliary atresia complicated with biliary ascites due to ductal perforation identified on a hepatobiliary iminodiacetic acid (HIDA) scan.
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Affiliation(s)
| | - Khalid Makhdomi
- Nuclear Medicine Division, Department of Radiology, Aga Khan University Hospital, Nairobi, Kenya
| | - Samuel Gitau
- PET/CT Imaging, Department of Radiology, Aga Khan University Hospital, Nairobi, Kenya
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Lu X, Jiang J, Shen Z, Chen G, Np YW, Xiao X, Yan W, Zheng S. Effect of Adjuvant Steroid Therapy in Type 3 Biliary Atresia: A Single-Center, Open-Label, Randomized Controlled Trial. Ann Surg 2023; 277:e1200-e1207. [PMID: 35170539 DOI: 10.1097/sla.0000000000005407] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the efficacy and side effects of additional postoperative steroid therapy for type 3 BA versus the current routine care. SUMMARY BACKGROUND DATA Whether steroid therapy post-Kasai portoen-terostomy improves the outcomes of BA remains controversial. Clinical evidence from 2 randomized trials in the UK and USA do not support the routine use of steroid in the treatment of BA. METHODS In this open-label randomized controlled trial, patients with type 3 BA were randomized to routine postoperative treatment with or without 10 to 12 weeks of adjuvant steroid treatment. The primary outcome was the postoperative jaundice clearance rate with native liver at 6 months. The secondary outcomes included postoperative jaundice clearance rate at 3, 12, and 24 months, survival with native liver at 12 and 24 months, and SAEs within 3 months. RESULTS Overall, 200 participants were randomized and allocated into either steroid or control group (n = 100/group). The proportion of participants that are jaundice free without liver transplantation was significantly higher in the steroid group than in the control group at 6 months (54.1% vs 31.0%, P = 0.0015). The native liver survival rate was higher postoperatively in the steroid group than in the control group at 12 (66.3% vs 50.0%, P = 0.02) and 24 (57.1% vs 40.0%, P = 0.02) months. The survival time with native liver was significantly longer in the steroid group than in the control group (median survival, steroid vs control: not reached vs 1.21 years, P = 0.02). There were no significant differences between the 2 groups in the mean occurrence of SAEs within 3 months (steroid vs control: 0.63 vs 0.45, P = 0.20). CONCLUSIONS Postoperative adjuvant steroid intervention improved bile drainage and survival with native liver in type 3 BA patients, without increasing early-stage SAEs.
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Affiliation(s)
- Xuexin Lu
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Jingying Jiang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Zhen Shen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Gong Chen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Ying Wu Np
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Xianmin Xiao
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Weili Yan
- Clinical Trial Unit (CTU), Children's Hospital of Fudan University, Shanghai, China
| | - Shan Zheng
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
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Zhong A, Short C, Xu J, Fernandez GE, Malkoff N, Noriega N, Yeo T, Wang L, Mavila N, Asahina K, Wang KS. Prominin-1 promotes restitution of the murine extrahepatic biliary luminal epithelium following cholestatic liver injury. Hepatol Commun 2023; 7:e0018. [PMID: 36662671 PMCID: PMC10019165 DOI: 10.1097/hc9.0000000000000018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/22/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND AND AIMS Restitution of the extrahepatic biliary luminal epithelium in cholangiopathies is poorly understood. Prominin-1 (Prom1) is a key component of epithelial ciliary body of stem/progenitor cells. Given that intrahepatic Prom1-expressing progenitor cells undergo cholangiocyte differentiation, we hypothesized that Prom1 may promote restitution of the extrahepatic bile duct (EHBD) epithelium following injury. APPROACH AND RESULTS Utilizing various murine biliary injury models, we identified Prom1-expressing cells in the peribiliary glands of the EHBD. These Prom1-expressing cells are progenitor cells which give rise to cholangiocytes as part of the normal maintenance of the EHBD epithelium. Following injury, these cells proliferate significantly more rapidly to re-populate the biliary luminal epithelium. Null mutation of Prom1 leads to significantly >10-fold dilated peribiliary glands following rhesus rotavirus-mediated biliary injury. Cultured organoids derived from Prom1 knockout mice are comprised of biliary progenitor cells with altered apical-basal cellular polarity, significantly fewer and shorter cilia, and decreased organoid proliferation dynamics consistent with impaired cell motility. CONCLUSIONS We, therefore, conclude that Prom1 is involved in biliary epithelial restitution following biliary injury in part through its role in supporting cell polarity.
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Affiliation(s)
- Allen Zhong
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children’s Hospital of Los Angeles, Los Angeles, California, USA
| | - Celia Short
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children’s Hospital of Los Angeles, Los Angeles, California, USA
| | - Jiabo Xu
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children’s Hospital of Los Angeles, Los Angeles, California, USA
| | - G. Esteban Fernandez
- Cellular Imaging Core, The Saban Research Institute, Children’s Hospital of Los Angeles, Los Angeles, California, USA
| | - Nicolas Malkoff
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children’s Hospital of Los Angeles, Los Angeles, California, USA
| | - Nicolas Noriega
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children’s Hospital of Los Angeles, Los Angeles, California, USA
| | - Theresa Yeo
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children’s Hospital of Los Angeles, Los Angeles, California, USA
| | - Larry Wang
- Department of Pathology, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Nirmala Mavila
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Kinji Asahina
- Central Research Laboratory, Shiga University of Medical Science, Ōtsu, Shiga Prefecture, Japan
| | - Kasper S. Wang
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children’s Hospital of Los Angeles, Los Angeles, California, USA
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Short C, Zhong A, Xu J, Mahdi E, Glazier A, Malkoff N, Noriega N, Yeo T, Asahina K, Wang KS. TWEAK/FN14 promotes profibrogenic pathway activation in Prominin-1-expressing hepatic progenitor cells in biliary atresia. Hepatology 2023; 77:1639-1653. [PMID: 36626628 DOI: 10.1097/hep.0000000000000026] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 10/01/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND AIMS Biliary atresia (BA), a congenital cholestatic liver disease, commonly culminates in end-stage liver disease. We previously demonstrated in BA that Prominin-1 ( Prom1 )-expressing hepatic progenitor cells (HPCs) expand within regions of developing fibrosis, giving rise to cholangiocytes within biliary ductular reactions. Null mutation of Prom1 or ablation of cells expressing Prom1 significantly diminishes fibrogenesis. FN14, the receptor for TNF-like weak inducer of apoptosis (TWEAK), is expressed by HPCs. TWEAK/FN14 signaling promotes fibrosis in multiple organ systems. Therefore, we hypothesized that TWEAK/FN14 signaling mediates Prom1 -expressing HPC proliferation leading to profibrogenic ductular reactions in BA. APPROACH AND RESULTS The experimental mouse model of BA mediated by perinatal rhesus rotavirus (RRV) infection resulted in increased co-expression of Fn14 in Prom1 -expressing HPCs within regions of ductular reactions. FN14 antagonist L524-0366 decreased ductular reactions, biliary fibrosis and periportal fibroblast activation in RRV injury. L524-0366 inhibition also demonstrated loss of downstream noncanonical NF-kB signaling expression in RRV injury. Murine HPC organoids demonstrated accelerated organoid growth and proliferation when treated with recombinant TWEAK. Increased organoid proliferation with recombinant TWEAK was lost when also treated with L524-0366. Analysis of a large publicly available RNA sequencing database of BA and normal control patients revealed significant increases in expression of PROM1 , FN14 , and genes downstream of TNF signaling and noncanonical NF-κB signaling pathways in BA infants. Infants who failed to achieve bile drainage after hepatoportoenterostomy had higher relative levels of FN14 expression. CONCLUSION TWEAK/FN14 signaling activation in Prom1 -expressing HPCs contributes to proliferation of profibrogenic ductular reactions in BA.
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Affiliation(s)
- Celia Short
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Allen Zhong
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Jiabo Xu
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Elaa Mahdi
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Alison Glazier
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Nicolas Malkoff
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Nicolas Noriega
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Theresa Yeo
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Kinji Asahina
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Central Research Laboratory, Shiga University of Medical Science, Ōtsu, Shiga Prefecture, Japan
| | - Kasper S Wang
- Developmental Biology, Regenerative Medicine, and Stem Cell Program, The Saban Research Institute, Children's Hospital of Los Angeles, Los Angeles, California, USA
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Siyu P, Junxiang W, Qi W, Yimao Z, Shuguang J. The Role of GLI in the Regulation of Hepatic Epithelial-Mesenchymal Transition in Biliary Atresia. Front Pediatr 2022; 10:861826. [PMID: 35692978 PMCID: PMC9178093 DOI: 10.3389/fped.2022.861826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/06/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To study the regulatory role of GLI1/GLI2, a nuclear transcription factor of the Sonic hedgehog (Shh) signaling pathway, in epithelial-mesenchymal transition (EMT) related to hepatic fibrosis in patients with biliary atresia (BA). METHODS The messenger RNA (mRNA) and protein expression levels of GLI1/GLI2, Snail/Slug, and other Shh- and EMT-related cytokines were tested in the liver tissues of BA patients and animals. Then, GLI1/GLI2 was silenced and overexpressed in mouse intrahepatic bile duct epithelial cells (mIBECs) and BA animals to investigate changes in the mRNA and protein expression of EMT key factors and liver fibrosis indicators. After silencing and overexpression of GLI1/GLI2, immunofluorescence was used to detect the expression of cytokeratin-19 (CK19) and α-smooth muscle actin (α-SMA) in mIBECs, and hematoxylin and eosin (HE) staining and Masson staining were used to observe the degree of liver fibrosis in the BA animals. RESULTS Compared with the control, the mRNA and protein expression levels of GLI2, Snail, vimentin, and α-SMA were significantly increased and those of E-cadherin were significantly decreased in liver tissue from BA patients and animals. Overexpression of GLI2 increased the mRNA and protein expression levels of Snail, vimentin, and α-SMA and that of E-cadherin was significantly decreased in mIBECs and BA animals. After GLI2 silencing, the opposite pattern was observed. Immunofluorescence detection showed enhanced expression of the bile duct epithelial cell marker CK19 in mIBECs after GLI2 silencing and enhanced expression of the mesenchymal cell marker α-SMA after GLI2 overexpression. HE and Masson staining suggested that the GLI2-overexpressing group had a significantly higher degree of fibrosis. CONCLUSION The Shh signaling pathway plays an important role in fibrogenesis in BA. GLI2 can significantly regulate EMT in mIBECs and livers of BA mice.
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Affiliation(s)
- Pu Siyu
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Wang Junxiang
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Wang Qi
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Zhang Yimao
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Jin Shuguang
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
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The triangular cord ratio and the presence of a cystic lesion in the triangular cord. Suggested new ultrasound findings in the early diagnosis of Biliary Atresia. Pediatr Surg Int 2021; 37:1693-1697. [PMID: 34524521 DOI: 10.1007/s00383-021-04997-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND In biliary atresia (BA), the ultrasonic triangular cord (TC) sign is positive at ≥ 3 mm, but sometimes there is BA even if it is ≤ 3 mm. For improving the ultrasonographic diagnosis, we have established a new evaluation, adding the ratio of the anterior/posterior thickness (TC ratio) in the hyperechoic area and the presence of a cystic lesion in the triangular cord (TCC). METHODS We examined 24 cases of suspected BA who demonstrated acholic stools from 2006 to 2020. We retrospectively reviewed the timing of ultrasonographic diagnosis, the gallbladder diameter, gallbladder mucosal irregularity, the TC sign, TCC, and the TC ratio. RESULTS In the BA group (n = 10) vs the Non-BA group (n = 14), the age at ultrasonography was 75 ± 41.7 vs. 81 ± 39.1 days (p = 0.72), the gallbladder diameter was 12.1 ± 9.7 vs. 24.2 ± 6.96 mm (p = 0.02), irregularity of gallbladder mucosa was 7 cases vs. 1 case (p < 0.01), and TC sign was 3.9 ± 1.3 vs. 2.0 ± 0.49 mm (p = 0.01), respectively. TCC was observed in 8/10 cases in the BA group and none in the Non-BA group (p < 0.01). TC ratio was 3.40 ± 0.68 (BA group) and 1.59 ± 0.41 (Non-BA group) (p < 0.01). CONCLUSION The ultrasonic TC ratio improves the diagnostic accuracy of BA. TCC is a specific finding in the BA group.
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Van Tung N, Lien NTK, Lan NN, Mai NTP, Yen PTH, Hoa NPA, Hoang NH. The role of p.Val444Ala variant in the ABCB11 gene and susceptibility to biliary atresia in Vietnamese patients. Medicine (Baltimore) 2021; 100:e28011. [PMID: 34964797 PMCID: PMC8615439 DOI: 10.1097/md.0000000000028011] [Citation(s) in RCA: 1] [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: 05/28/2021] [Accepted: 11/11/2021] [Indexed: 11/26/2022] Open
Abstract
Biliary atresia (BA) is the most serious type of obstructive cholangiopathy that occurs in infants. BA can be the cause of death in children under 2 years if untreated early. However, the etiology of the disease is not known. BA is considered to be the result of the destruction of the bile duct system including the accumulation of bile acids. The bile salt export pump, a transporter protein encoded by the ABCB11 gene, plays the main role in the exportation and accumulation of bile acids. The p.Val444Ala variant in this gene is known to be associated with many cholestatic diseases. However, to date no study have been performed to evaluate the association of this variant with susceptibility to the risk of BA. In this study, we aimed to identify the frequency of p.Val444Ala variant and the risk of BA in Vietnamese patients.The polymerase chain reaction (PCR)- restriction fragment length polymorphism method was used to determine the frequency of alleles c.1331T>C (p.Val444Ala, rs2287622) in the ABCB11 gene in 266 Vietnamese patients with BA and 150 healthy people. The gene segment containing the variant was amplified by PCR with specific primers, after that the PCR products were cut by HaeIII restriction enzyme and analyzed on agarose gel to determine the genotypes. The frequency of alleles was assessed statistically to determine the association between these alleles and the risk of disease in patients.In our study, the frequency of alleles c.1331T>C (p.Val444Ala, rs2287622) in the ABCB11 gene was investigated the first time in the patients with BA. The results showed that CC and TC genotypes were significantly different between BA patients and healthy people (P < .01), and the C allele was associated with an increased risk of BA (odds ratio = 2.47; 95% confidence interval: 1.84-3.32; P < .01). The initial results of clinical, biochemical, and genetic analysis in our study suggested that the p.Val444Ala variant in the ABCB11 gene may be a susceptibility factor for the disease in Vietnamese patients with BA. These results provided new insights into the role of this ABCB11 variant in the pathogenesis of BA.
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Affiliation(s)
- Nguyen Van Tung
- Institute of Genome Research, Vietnam Academy of Science and Technology, Vietnam
- Graduate University of Science and Technology, Vietnam Academy of Science and Technology, Vietnam
| | - Nguyen Thi Kim Lien
- Institute of Genome Research, Vietnam Academy of Science and Technology, Vietnam
| | - Nguyen Ngoc Lan
- Institute of Genome Research, Vietnam Academy of Science and Technology, Vietnam
| | | | - Pham Thi Hai Yen
- Vietnam National Children's Hospital, Ministry of Health, Vietnam
| | | | - Nguyen Huy Hoang
- Institute of Genome Research, Vietnam Academy of Science and Technology, Vietnam
- Graduate University of Science and Technology, Vietnam Academy of Science and Technology, Vietnam
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Larrosa-Haro A, Caro-Sabido EA. Secondary Malnutrition and Nutritional Intervention in Cholestatic Liver Diseases in Infants. Front Nutr 2021; 8:716613. [PMID: 34869514 PMCID: PMC8636107 DOI: 10.3389/fnut.2021.716613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/22/2021] [Indexed: 12/12/2022] Open
Abstract
We aimed to conduct an updated review on the pathophysiology, diagnosis, and nutritional intervention of CCLD and secondary malnutrition in infants. Protein-energy malnutrition, impaired linear growth, fat-soluble vitamin deficiencies, and hepatic osteodystrophy can occur in up to 80% of cases. The proposed pathophysiological mechanisms include insufficient energy intake, lipid- and fat-soluble vitamin malabsorption, increased energy expenditure, altered intermediate metabolism, hormonal dysregulation, and systemic inflammation. The current approach to diagnosis is the identification of the deviation of growth parameters, body composition, and serum concentration of micronutrients, which determines the type and magnitude of malnutrition. Currently, liver transplantation is the best therapeutic alternative for the reversal of nutritional impairment. Early and effective portoenteroanatomosis can extend survival in patients with biliary atresia. Medical and dietary interventions in some storage and metabolic diseases can improve liver damage and thus the nutritional status. A proportion of patients with biliary atresia have fat-soluble vitamin deficiencies despite receiving these vitamins in a water-soluble form. With aggressive enteral nutrition, it may be possible to increase fat stores and preserve muscle mass and growth. The nutritional issues identified in the pre- and post-transplantation stages include muscle mass loss, bone demineralization, growth retardation, and obesity, which seems to correspond to the natural history of CCLD. Due to the implications for the growth and development of infants with CCLD with this complex malnutrition syndrome, innovative projects are required, such as the generation of prediction and risk models, biomarkers of growth and body composition, and effective strategies for nutritional prevention and intervention.
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Affiliation(s)
- Alfredo Larrosa-Haro
- Instituto de Nutrición Humana, Departamento de Clínicas de la Reproducción Humana, Crecimiento y Desarrollo Infantil, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
| | - Erika A. Caro-Sabido
- Departamento de Salud Pública, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
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Brovold M, Keller D, Devarasetty M, Dominijanni A, Shirwaiker R, Soker S. Biofabricated 3D in vitro model of fibrosis-induced abnormal hepatoblast/biliary progenitors' expansion of the developing liver. Bioeng Transl Med 2021; 6:e10207. [PMID: 34589593 PMCID: PMC8459590 DOI: 10.1002/btm2.10207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/25/2020] [Accepted: 11/29/2020] [Indexed: 11/19/2022] Open
Abstract
Congenital disorders of the biliary tract are the primary reason for pediatric liver failure and ultimately for pediatric liver transplant needs. Not all causes of these disorders are well understood, but it is known that liver fibrosis occurs in many of those afflicted. The goal of this study is to develop a simple yet robust model that recapitulates physico-mechanical and cellular aspects of fibrosis mediated via hepatic stellate cells (HSCs) and their effects on biliary progenitor cells. Liver organoids were fabricated by embedding various HSCs, with distinctive abilities to generate mild to severe fibrotic environments, together with undifferentiated liver progenitor cell line, HepaRG, within a collagen I hydrogel. The fibrotic state of each organoid was characterized by examination of extracellular matrix (ECM) remodeling through quantitative image analysis, rheometry, and qPCR. In tandem, the phenotype of the liver progenitor cell and cluster formation was assessed through histology. Activated HSCs (aHSCs) created a more severe fibrotic state, exemplified by a more highly contracted and rigid ECM, as well higher relative expression of TGF-β, TIMP-1, LOXL2, and COL1A2 as compared to immortalized HSCs (LX-2). Within the more severe fibrotic environment, generated by the aHSCs, higher Notch signaling was associated with an expansion of CK19+ cells as well as the formation of larger, more densely populated cell biliary like-clusters as compared to mild and non-fibrotic controls. The expansion of CK19+ cells, coupled with a severely fibrotic environment, are phenomena found within patients suffering from a variety of congenital liver disorders of the biliary tract. Thus, the model presented here can be utilized as a novel in vitro testing platform to test drugs and identify new targets that could benefit pediatric patients that suffer from the biliary dysgenesis associated with a multitude of congenital liver diseases.
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Affiliation(s)
- Matthew Brovold
- Wake Forest Institute for Regenerative MedicineWake Forest Baptist Medical Center, Medical Center BoulevardWinston‐SalemNorth CarolinaUSA
| | - Dale Keller
- Wake Forest Institute for Regenerative MedicineWake Forest Baptist Medical Center, Medical Center BoulevardWinston‐SalemNorth CarolinaUSA
| | - Mahesh Devarasetty
- Wake Forest Institute for Regenerative MedicineWake Forest Baptist Medical Center, Medical Center BoulevardWinston‐SalemNorth CarolinaUSA
| | - Anthony Dominijanni
- Wake Forest Institute for Regenerative MedicineWake Forest Baptist Medical Center, Medical Center BoulevardWinston‐SalemNorth CarolinaUSA
| | - Rohan Shirwaiker
- Department of Industrial and Systems EngineeringNorth Carolina State UniversityRaleighNorth CarolinaUSA
| | - Shay Soker
- Wake Forest Institute for Regenerative MedicineWake Forest Baptist Medical Center, Medical Center BoulevardWinston‐SalemNorth CarolinaUSA
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11
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Jaffey JA. Canine hepatobiliary anatomy, physiology and congenital disorders. J Small Anim Pract 2021; 63:95-103. [PMID: 34409602 DOI: 10.1111/jsap.13410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/21/2021] [Accepted: 07/27/2021] [Indexed: 11/29/2022]
Abstract
The biliary system is an integral component of normal physiologic homeostasis and essential for survival. It acts as a conduit for the removal of detoxified and catabolised compounds as well as aids in fat digestion and absorption. Derangements in this system can have dangerous sequela that are associated with varying degrees of morbidity and mortality. Moreover, abnormalities in development of the biliary system can have varied and unpredictable changes on function and long-term outcome. The aims of this article were to review canine hepatobiliary anatomy, physiology and cholestasis as well as summarise congenital biliary disorders including human corollaries.
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Affiliation(s)
- J A Jaffey
- Department of Specialty Medicine, College of Veterinary Medicine, Midwestern University, Glendale, Arizona, USA
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12
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Misra S, Majumdar K, Sakhuja P, Jain P, Singh L, Kumar P, Dubey AP. Differentiating Biliary Atresia From Idiopathic Neonatal Hepatitis: A Novel Keratin 7 Based Mathematical Approach on Liver Biopsies. Pediatr Dev Pathol 2021; 24:103-115. [PMID: 33439108 DOI: 10.1177/1093526620983730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Differentiating biliary atresia (BA) from idiopathic neonatal hepatitis (INH) is vital in routine pediatric practice. However, on liver biopsy, few cases offer a diagnostic challenge to discriminate these entities with certainty. Bile ductular reaction (DR), intermediate hepatobiliary cells (IHBC) and extra-portal ductules (EPD) indicate progenitor cell activation, as a response to various hepatic insults. The present study aims to quantify DR, IHBC and EPD by Keratin 7 (CK7) immunohistochemistry (IHC) in BA and INH and to devise a mathematical approach to better differentiate the two, especially in histologically equivocal cases. METHODS A total of 98 cases were categorized on biopsy as BA, INH or equivocal histology, favoring BA or INH. CK7 DR mean, IHBC mean and EPD mean values were compared between BA and INH. A formula was derived to help distinguish these two entities, the cut-off value, sensitivity and specificity of which were determined by receiver operating characteristic (ROC) curve. This formula was applied and validated on histologically equivocal cases. RESULTS Univariate logistic regression revealed significant difference between BA and INH with respect to CK7 DR and CK7 EPD mean (p < 0.001 in both); however, CK7 IHBC mean was not significant (p = 0.08). On multivariate logistic regression, only CK7 DR had significant impact on diagnosis (p < 0.001). A formula: (CK7 DR)2 + (CK7 EPD)/(CK7 IHBC) was derived to help distinguish BA from INH. Cut off value of 10.5 and above, determined by ROC curve, favored a diagnosis of BA (sensitivity= 93.4%, specificity= 94.6%). Histologically equivocal and discrepant cases could be correctly categorized using this formula. CONCLUSIONS Formula using CK7 IHC parameters may aid pathologists better distinguish BA from INH, especially in histologically equivocal cases.
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Affiliation(s)
- Sunayana Misra
- Department of Pathology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Kaushik Majumdar
- Department of Pathology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Puja Sakhuja
- Department of Pathology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Priyanka Jain
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Lavleen Singh
- Department of Pathology, Chacha Nehru Bal Chikitsalaya, New Delhi, India
| | - Praveen Kumar
- Department of Pediatrics, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, India
| | - A P Dubey
- Department of Pediatrics, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, India
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Chan KL, Varughese N, Jones PM, Zwick DL, Rajaram V, Lee M, Ramirez CM. A Case of Dubin-Johnson Syndrome Presenting as Neonatal Cholestasis With Paucity of Interlobular Bile Ducts. Pediatr Dev Pathol 2021; 24:154-158. [PMID: 33470920 DOI: 10.1177/1093526620980577] [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] [Indexed: 11/16/2022]
Abstract
Dubin-Johnson syndrome (DJS) is a rare autosomal recessive disorder that typically manifests in young adulthood as jaundice with conjugated hyperbilirubinemia. We report a case presenting as neonatal cholestasis with the unexpected histologic finding of paucity of interlobular bile ducts, a feature that is not typically seen in DJS. The diagnosis was confirmed by absent canalicular multidrug-resistance-associated protein 2 (MRP2) immunohistochemical staining on liver biopsy tissue and molecular genetic testing that demonstrated heterozygous mutations in the ATP-Binding Cassette Subfamily C Member 2 (ABCC2) gene, including a novel missense mutation. This report describes a case of DJS with atypical clinicopathologic findings and suggests that DJS should be considered in patients with neonatal cholestasis and bile duct paucity.
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Affiliation(s)
- Kara L Chan
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Natasha Varughese
- Department of Pediatrics, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Patricia M Jones
- Department of Pathology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - David L Zwick
- Department of Pathology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Veena Rajaram
- Department of Pathology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Michael Lee
- Department of Pediatrics, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Charina M Ramirez
- Department of Pediatrics, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
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14
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Zhao D, Gu S, Gong X, Li Y, Sun X, Chen Y, Deng Z, Zhang Y. Web-based calculator for biliary atresia screening in neonates and infants with cholestasis. Transl Pediatr 2021; 10:225-235. [PMID: 33708508 PMCID: PMC7944186 DOI: 10.21037/tp-20-170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Distinguishing biliary atresia from non-biliary atresia in patients with cholestasis is challenging, as these conditions have a similar clinical presentation. We developed and externally validated a screening model for biliary atresia and devised a web-based calculator for use in clinical settings. METHODS A screening model was developed based on data from 227 cholestatic infants (82 and 145 with and without biliary atresia, respectively) and validated in 234 infants (90 and 144 with and without biliary atresia, respectively) admitted to three hospitals. Variables were selected from routine examination results using the least absolute shrinkage and selection operator method and entered into a logistic regression model to construct a biliary-atresia-risk-predicting equation. Cutoff values for risk stratification were estimated using model sensitivity, derived from the receiver-operating characteristic curves. RESULTS The final screening model included seven variables (i.e., weight at admission, clay-colored stools, γ-glutamyl transpeptidase and albumin levels at admission, abnormal gallbladder, triangular cord sign, and change in total bilirubin levels). The model generated an area under the curve of 0.94 with a sensitivity of 91.46 and specificity of 86.62 in the derivation cohort. This was confirmed in the validation cohort, as we found an area under the curve of 0.93 with a sensitivity of 93.1 and specificity of 80.15. Patients were stratified into three risk groups (low-, moderate-, and high-risk groups). Biliary atresia was excluded in the low-risk group. The high-risk group showed a higher detection rate of biliary atresia compared to the stool color screening method alone. This model was integrated into a user-friendly web-based system. CONCLUSIONS The screening tool had a high predictive value and may help in decision-making by physicians at tertiary and community hospitals.
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Affiliation(s)
- Dongying Zhao
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Shengli Gu
- Department of Ultrasound, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xiaohui Gong
- Department of Neonatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yahui Li
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xiaoang Sun
- Department of Pediatric Digestive Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Chen
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Zhaohui Deng
- Department of Pediatric Digestive Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yongjun Zhang
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
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15
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Aboughalia H, Kim HH, Dick AAS, Pacheco MC, Cilley RE, Iyer RS. Pediatric biliary disorders: Multimodality imaging evaluation with clinicopathologic correlation. Clin Imaging 2021; 75:34-45. [PMID: 33493735 DOI: 10.1016/j.clinimag.2021.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/04/2020] [Accepted: 01/04/2021] [Indexed: 11/15/2022]
Abstract
The spectrum of pathologies affecting the biliary tree in the pediatric population varies depending on the age of presentation. While in utero insults can result in an array of anatomic variants and congenital anomalies in newborns, diverse acquired biliary pathologies are observed in older children. These acquired pathologies display different presentations and consequences than adults. Multimodality imaging assessment of the pediatric biliary system is requisite to establishing an appropriate management plan. Awareness of the imaging features of the various biliary pathologies and conveying clinically actionable information is essential to facilitate appropriate patient management. In this paper, we will illustrate the anatomy and embryology of the pediatric biliary system. Then, we will provide an overview of the imaging modalities used to assess the biliary system. Finally, we will review the unique features of the pediatric biliary pathologies, complemented by histopathologic correlation and discussions of clinical management.
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Affiliation(s)
- Hassan Aboughalia
- Radiology Department, University of Washington Medical Center, Seattle, WA 98195, United States of America.
| | - Helen Hr Kim
- Radiology Department, Seattle Children's Hospital, University of Washington School of Medicine, 98105, United States of America.
| | - Andre A S Dick
- Department of Surgery, Section of Pediatric Transplant, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, 98105, United States of America.
| | - M Cristina Pacheco
- Department of Pathology, University of Washington, Department of Laboratories, Seattle Children's Hospital, United States of America.
| | - Robert E Cilley
- Children's Surgery Center, Penn State Children's Hospital, Milton S. Hershey Medical Center, United States of America.
| | - Ramesh S Iyer
- Radiology Department, Seattle Children's Hospital, University of Washington School of Medicine, 98105, United States of America.
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Hattori K, Hamada Y, Sato M. Cyst Size in Fetuses with Biliary Cystic Malformation: An Exploration of the Etiology of Congenital Biliary Dilatation. Pediatr Gastroenterol Hepatol Nutr 2020; 23:531-538. [PMID: 33215024 PMCID: PMC7667227 DOI: 10.5223/pghn.2020.23.6.531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 05/06/2020] [Accepted: 06/16/2020] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Our aim was the longitudinal assessment of cyst size in fetuses with biliary cystic malformation (BCM) to explore its etiology and the possibility of antenatal differentiation between biliary atresia (BA) and congenital biliary dilatation (CBD). METHODS We conducted a retrospective review of all patients diagnosed antenatally with BCM from 1994 to 2014 at our institutions. RESULTS The study cohort comprised of three patients with BA and six with CBD. There were no significant differences in the gestational age and cyst size at the first detection of BCM between the two groups. In fetuses with CBD, the cyst size steadily increased as the gestational age advanced, while it fluctuated around 1.5 cm and remained below 2.1 cm in those with BA. However, the ratio of cystic area to fetal trunk area was approximately constant due to linear fetal growth in fetuses with CBD. CONCLUSION Fetuses with BCM <2.1 cm in the late gestation period were more likely to have BA than CBD. Our observation of cyst enlargement with advancing gestational age in the CBD group was attributed solely to fetal growth. Biliary dilatation in fetuses with CBD and BA might be completed at the onset of BCM.
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Affiliation(s)
- Kengo Hattori
- Department of Pediatric Surgery, Takatsuki General Hospital, Osaka, Japan.,Division of Pediatric Surgery, Kansai Medical University, Osaka, Japan
| | - Yoshinori Hamada
- Division of Pediatric Surgery, Kansai Medical University, Osaka, Japan
| | - Masahito Sato
- Department of Pediatric Surgery, Kitano Hospital, Osaka, Japan
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Karpen SJ, Kelly D, Mack C, Stein P. Ileal bile acid transporter inhibition as an anticholestatic therapeutic target in biliary atresia and other cholestatic disorders. Hepatol Int 2020; 14:677-689. [PMID: 32653991 DOI: 10.1007/s12072-020-10070-w] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/22/2020] [Indexed: 12/20/2022]
Abstract
Biliary atresia is a rare cholestatic liver disease that presents in infants and rapidly advances to death in the absence of intervention. As a result of blockage or destruction of the biliary tract, bile acids accumulate and drive inflammation, fibrosis, and disease progression. The standard of care, Kasai portoenterostomy (KPE), is typically performed shortly after diagnosis (currently at ~ 2 months of age) and aims to restore bile flow and relieve cholestasis. Nevertheless, most patients continue to experience liver injury from accumulation of bile acids after KPE, since there are no known effective therapeutics that may enhance survival after KPE. Improving cholestasis via interruption of the enterohepatic circulation of bile acids may directly attenuate hepatic bile acid retention and reduce the risk of early organ failure. Directly addressing intrahepatic accretion of bile acids to avoid inherent bile acid toxicities provides an attractive and plausible therapeutic target for biliary atresia. This review explores the novel therapeutic concept of inhibiting the sole ileal bile acid transporter (IBAT), also known as ASBT (apical sodium-bile acid transporter, encoded by SLC10A2), as a means to reduce hepatic bile acid concentration after KPE. By reducing return of bile acids to the cholestatic liver, IBAT inhibitors may potentially lessen or delay liver damage associated with the hepatotoxicity and cholangiopathy of bile acid accumulation. The clinical programs of 2 IBAT inhibitors in development for the treatment of pediatric cholestatic liver diseases, maralixibat and odevixibat, are highlighted.
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Affiliation(s)
- Saul J Karpen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine and Children's Healthcare of Atlanta, 1760 Haygood Dr., HSRB E204, Atlanta, GA, 30322, USA.
| | - Deirdre Kelly
- Liver Unit, Birmingham Women's and Children's NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Cara Mack
- Section of Pediatric Gastroenterology, Hepatology and Nutrition and the Digestive Health Institute, University of Colorado School of Medicine and Children's Hospital Colorado, 13123 E 16th Ave B290, Aurora, CO, 80045, USA
| | - Philip Stein
- Medical Affairs, Albireo Pharma, Inc, 10 Post Office Square, Suite 1000, Boston, MA, 02109, USA
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18
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Smith M, Zuckerman M, Kandanearatchi A, Thompson R, Davenport M. Using next-generation sequencing of microRNAs to identify host and/or pathogen nucleic acid signatures in samples from children with biliary atresia - a pilot study. Access Microbiol 2020; 2:acmi000127. [PMID: 32974591 PMCID: PMC7497833 DOI: 10.1099/acmi.0.000127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 02/24/2020] [Indexed: 12/11/2022] Open
Abstract
Biliary atresia (BA) is a progressive disease affecting infants resulting in inflammatory obliteration and fibrosis of the extra- and intra-hepatic biliary tree. BA may be grouped into type 1 isolated; type 2 syndromic, where other congenital malformations may be present; type 3 cystic BA, where there is cyst formation within an otherwise obliterated biliary tree; and cytomegalovirus-associated BA. The cause of BA is unclear, with immune dysregulation, inflammation and infection, particularly with cytomegalovirus (CMV), all implicated. In this study a total of 50/67 samples were tested for CMV DNA using quantitative real-time PCR. Ten liver tissue and 8 bile samples from 10 patients representing the range of BA types were also analysed by next-generation sequencing. CMV DNA was found in 8/50 (16 %) patients and a total of 265 differentially expressed microRNAs were identified. No statistically significant differences between the various types of BA were found. However, differences were identified in the expression patterns of 110 microRNAs in bile and liver tissue samples (P<0.05). A small number of bacterial and viral sequences were found, although their relevance to BA remains to be determined. No direct evidence of viral causes of BA were found, although clear evidence of microRNAs associated with hepatocyte and cholangiocyte differentiation together with fibrosis and inflammation were identified. These include miR-30 and the miR-23 cluster (liver and bile duct development) and miR-29, miR-483, miR-181, miR-199 and miR-200 (inflammation and fibrosis).
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Affiliation(s)
- Melvyn Smith
- Viapath Analytics, South London Specialist Virology Centre, Denmark Hill, London
| | - Mark Zuckerman
- Viapath Analytics, South London Specialist Virology Centre, Denmark Hill, London
| | | | - Richard Thompson
- Institute of Liver Studies and Paediatric Liver Services, Denmark Hill, London
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS
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19
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Reduced Immunohistochemical Expression of Hnf1β and FoxA2 in Liver Tissue Can Discriminate Between Biliary Atresia and Other Causes of Neonatal Cholestasis. Appl Immunohistochem Mol Morphol 2020; 27:e32-e38. [PMID: 29406331 DOI: 10.1097/pai.0000000000000638] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Biliary atresia (BA) is a necroinflammatory occlusive cholangiopathy that affects infants. Genetic and environmental factors has been proposed for its occurrence. The objectives of this study was to investigate the protein expression of 2 important genes regulating ductal plate remodeling, hepatocyte nuclear factor 1-beta (Hnf1β) and the fork head box protein A2 (FoxA2) in liver tissue from patients with BA and to compare their expression with other causes of neonatal cholestasis (NC). This retrospective study included 60 pediatric patients, 30 with BA and 30 with NC. Immunohistochemistry of Hnf1β and FoxA2 was performed on liver tissues from studied patients as well as 20 healthy subjects. Statistical analysis between immunohistochemistry results and other parameters was performed. Liver tissue from patients with BA revealed reduced Hnf1β and FoxA2 immunoexpression. A strong significant statistical difference between BA and NC group (P<0.0001) with regard to Hnf1β and FoxA2 immunoexpression was evident. Moreover, Hnf1β was significantly correlated with FoxA2 immunoexpression, stage of fibrosis, bile ductular proliferation, and bile plugs in bile ductules. Hnf1β immunoreaction in BA cases showed 76.7% sensitivity, 90% specificity, 88.5% positive predictive value, 79.4% negative predictive value, and 83.4% accuracy. FoxA2 expression in BA cases revealed 70.0% sensitivity, 80.0% specificity, 77.8% positive predictive value, 72.7% negative predictive value, 75.0% accuracy. Hnf1β and FoxA2 immunoexpression could differentiate between BA from other cause of NC.
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20
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Mohanty SK, Lobeck I, Donnelly B, Dupree P, Walther A, Mowery S, Coots A, Bondoc A, Sheridan RM, Poling HM, Temple H, McNeal M, Sestak K, Bansal R, Tiao G. Rotavirus Reassortant-Induced Murine Model of Liver Fibrosis Parallels Human Biliary Atresia. Hepatology 2020; 71:1316-1330. [PMID: 31442322 PMCID: PMC7384231 DOI: 10.1002/hep.30907] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 08/15/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Biliary atresia (BA) is a devastating neonatal cholangiopathy that progresses to fibrosis and end-stage liver disease by 2 years of age. Portoenterostomy may reestablish biliary drainage, but, despite drainage, virtually all afflicted patients develop fibrosis and progress to end-stage liver disease requiring liver transplantation for survival. APPROACH AND RESULTS In the murine model of BA, rhesus rotavirus (RRV) infection of newborn pups results in a cholangiopathy paralleling human BA and has been used to study mechanistic aspects of the disease. Unfortunately, nearly all RRV-infected pups succumb by day of life 14. Thus, in this study we generated an RRV-TUCH rotavirus reassortant (designated as TR(VP2,VP4) ) that when injected into newborn mice causes an obstructive jaundice phenotype with lower mortality rates. Of the mice that survived, 63% developed Ishak stage 3-5 fibrosis with histopathological signs of inflammation/fibrosis and bile duct obstruction. CONCLUSIONS This model of rotavirus-induced neonatal fibrosis will provide an opportunity to study disease pathogenesis and has potential to be used in preclinical studies with an objective to identify therapeutic targets that may alter the course of BA.
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Affiliation(s)
- Sujit K. Mohanty
- Department of Pediatric and Thoracic SurgeryCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Inna Lobeck
- Department of Pediatric and Thoracic SurgeryCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Bryan Donnelly
- Department of Pediatric and Thoracic SurgeryCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Phylicia Dupree
- Department of Pediatric and Thoracic SurgeryCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Ashley Walther
- Department of Pediatric and Thoracic SurgeryCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Sarah Mowery
- Department of Pediatric and Thoracic SurgeryCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Abigail Coots
- Department of Pediatric and Thoracic SurgeryCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Alexander Bondoc
- Department of Pediatric and Thoracic SurgeryCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Rachel M. Sheridan
- Division of Pathology and Laboratory MedicineCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Holly M. Poling
- Department of Pediatric and Thoracic SurgeryCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Haley Temple
- Department of Pediatric and Thoracic SurgeryCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Monica McNeal
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOH,Division of Infectious DiseasesCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Karol Sestak
- Tulane National Primate Research CenterCovingtonLA
| | - Ruchi Bansal
- Department of Biomaterials Science and Technology, Technical Medical CentreUniversity of TwenteEnschedethe Netherlands
| | - Greg Tiao
- Department of Pediatric and Thoracic SurgeryCincinnati Children’s Hospital Medical CenterCincinnatiOH
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Abstract
Biliary atresia is a progressive fibrosing obstructive cholangiopathy of the intrahepatic and extrahepatic biliary system, resulting in obstruction of bile flow and neonatal jaundice. Histopathological findings in liver biopsies include the expansion of the portal tracts, with edematous fibroplasia and bile ductular proliferation, with bile plugs in duct lumen. Lobular morphological features may include variable multinucleate giant cells, bilirubinostasis and hemopoiesis. The etiopathogenesis of biliary atresia is multifactorial and multiple pathomechanisms have been proposed. Experimental and clinical studies have suggested that viral infection initiates biliary epithelium destruction and release of antigens that trigger a Th1 immune response, which leads to further injury of the bile duct, resulting in inflammation and obstructive scarring of the biliary tree. It has also been postulated that biliary atresia is caused by a defect in the normal remodelling process. Genetic predisposition has also been proposed as a factor for the development of biliary atresia.
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22
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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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Sujka J, Weaver KL, Poola AS, Rivard DC, Hendrickson RJ. Percutaneous transhepatic cholecysto-cholangiography (PTCC): An alternative to intraoperative cholangiography in high risk infants suspect for biliary atresia. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2018.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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Chawla V, Anagnost MR, Eldemerdash AE, Reyes D, Scherr R, Ezeanolue K, Banfro F, Alhosh R. A Novel Case of Biliary Atresia in a Premature Neonate With 1p36 Deletion Syndrome. J Investig Med High Impact Case Rep 2018; 6:2324709618790613. [PMID: 30057923 PMCID: PMC6058419 DOI: 10.1177/2324709618790613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 06/14/2018] [Accepted: 06/24/2018] [Indexed: 01/28/2023] Open
Abstract
We describe the case of a premature male neonate diagnosed with biliary atresia who was found to have chromosome 1p36 deletion syndrome. Our patient was born prematurely, at a gestational age of 28 weeks. Pregnancy was complicated by advanced maternal age, gestational hypertension, and intrauterine growth restriction. Physical examination revealed several dysmorphic features, prompting a genetic evaluation, which revealed chromosome 1p36 deletion syndrome. At week 7 of life, he was found to have acholic stools. Direct bilirubin was found to be elevated despite discontinuation of total parenteral nutrition at 3 weeks of life, thus raising the suspicion for biliary atresia. Biliary atresia was confirmed by constellation of clinical, imaging and intraoperative findings. First reported in 1996, 1p36 deletion syndrome has been researched increasingly and several new phenotypic associations have been reported over the years. While attempts at linking specific phenotypic abnormalities with individual gene(s) deletion(s) are being made, deletion patterns that would affect specific organ system or function remain to be fully understood. Thus, clinicians currently rely on reports of previously identified abnormalities. To our knowledge, our patient is the first report of biliary atresia in a patient with chromosome 1p36 deletion syndrome. It is important to determine the etiology of the cholestasis, when present, while caring for premature neonates with 1p36 deletion syndrome. This is necessary to avoid assuming that the cholestasis is arising from total parenteral nutrition administration and not from other gastrointestinal anomalies including biliary atresia, which is a time-sensitive diagnosis.
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Affiliation(s)
| | | | | | - Dahna Reyes
- University Medical Center, Las Vegas, NV, USA
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Laochareonsuk W, Chiengkriwate P, Sangkhathat S. Single nucleotide polymorphisms within Adducin 3 and Adducin 3 antisense RNA1 genes are associated with biliary atresia in Thai infants. Pediatr Surg Int 2018; 34:515-520. [PMID: 29508064 DOI: 10.1007/s00383-018-4243-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND A genome-wide association study in East Asians suggested a genetic association between biliary atresia (BA) and a cluster of variants within the Adducin 3 (ADD3) and ADD3 antisense RNA1 (ADD3-AS1) genes. Another study in Thai neonates reported an association between BA and rs17095355. To validate those findings, this study aimed to analyze the BA association with single nucleotide polymorphisms (SNPs) and the additive influence of ADD3 and ADD3-AS1 in Thai neonates. METHODS DNAs from 56 BA cases and 166 controls were genotyped for rs2501577, rs11194981, rs12268910 (ADD3) and rs17095355 (ADD3-AS1), using TaqMan PCR. Genotype distributions were compared between the groups, and SNP-SNP interactions were analyzed by combination of allelotypes. RESULTS The risk allele frequencies of rs2501577, rs11194981, and rs17095355 in the BA group were significantly higher than in the controls. Univariate analysis showed that recessive variants in the three SNPs were associated with BA risk at ORs of 1.81 (95% CI 1.32-2.50), 1.58 (95% CI 1.14-2.20) and 1.92 (95% CI 1.39-2.66), respectively. SNP-SNP interaction analysis showed that the SNP combination of the two genes rs17095355 and rs2501577 provided an additive increase in BA risk. CONCLUSION ADD3 and ADD3-AS1 variants increased susceptibility to BA, suggesting that these genes may play an additive role in the pathogenesis of the disease. In addition, these interactions may give a clue to the overexpression of the ADD3 protein in the liver of BA patients.
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Affiliation(s)
- Wison Laochareonsuk
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Piyawan Chiengkriwate
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Surasak Sangkhathat
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
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Ghazy RM, Adawy NM, Khedr MA, Tahoun MM. Biliary atresia recent insight. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2018. [DOI: 10.1016/j.epag.2017.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Sangkhathat S, Laochareonsuk W, Maneechay W, Kayasut K, Chiengkriwate P. Variants Associated with Infantile Cholestatic Syndromes Detected in Extrahepatic Biliary Atresia by Whole Exome Studies: A 20-Case Series from Thailand. J Pediatr Genet 2018; 7:67-73. [PMID: 29707407 DOI: 10.1055/s-0038-1632395] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 01/14/2018] [Indexed: 02/08/2023]
Abstract
Biliary atresia (BA) is the most severe form of obstructive cholangiopathy occurring in infants. Definitive diagnosis of BA usually relies on operative findings together with supporting pathological patterns found in the extrahepatic bile duct. In infancy, overlapping clinical patterns of cholestasis can be found in other diseases including biliary hypoplasia and progressive familial intrahepatic cholestasis. In addition, BA has been reported as a phenotype in some rare genetic syndromes. Unlike BA, other cholangiopathic phenotypes have their own established genetic markers. In this study, we used these markers to look for other cholestasis entities in cases diagnosed with BA. DNA from 20 cases of BA, diagnosed by operative findings and histopathology, were subjected to a study of 19 genes associated with infantile cholestasis syndromes, using whole exome sequencing. Variant selection focused on those with allele frequencies in dbSNP150 of less than 0.01. All selected variants were verified by polymerase chain reaction-direct sequencing. Of the 20 cases studied, 13 rare variants were detected in 9 genes: 4 in JAG1 (Alagille syndrome), 2 in MYO5B (progressive familial intrahepatic cholestasis [PFIC] type 6), and one each in ABCC2 (Dubin-Johnson syndrome), ABCB11 (PFIC type 2), UG1A1 (Crigler-Najjar syndrome), MLL2 (Kabuki syndrome), RFX6 (Mitchell-Riley syndrome), ERCC4 (Fanconi anemia), and KCNH1 (Zimmermann-Laband syndrome). Genetic lesions associated with various cholestatic syndromes detected in cases diagnosed with BA raised the hypothesis that severe inflammatory cholangiopathy in BA may not be a distinct disease entity, but a shared pathology among several infantile cholestatic syndromes.
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Affiliation(s)
- Surasak Sangkhathat
- Pediatric Surgery Unit, Department of Surgery, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Wison Laochareonsuk
- Pediatric Surgery Unit, Department of Surgery, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Wanwisa Maneechay
- Central Research Laboratory, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Kanita Kayasut
- Anatomical Pathology Unit, Department of Pathology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Piyawan Chiengkriwate
- Pediatric Surgery Unit, Department of Surgery, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Huang SY, Yeh CM, Chen HC, Chou CM. Reconsideration of Laparoscopic Kasai Operation for Biliary Atresia. J Laparoendosc Adv Surg Tech A 2018; 28:229-234. [DOI: 10.1089/lap.2017.0535] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Sheng-Yang Huang
- Division of Pediatric Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C
| | - Chou-Ming Yeh
- Taichung Hospital, Ministry of Health and Welfare, Executive Yuan, Taiwan, R.O.C
| | - Hou-Chuan Chen
- Division of Pediatric Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C
| | - Chia-Man Chou
- Division of Pediatric Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C
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Garrido M, Escobar C, Zamora C, Rejas C, Varas J, Párraga M, San Martin S, Montedónico S. Bile duct ligature in young rats: A revisited animal model for biliary atresia. Eur J Histochem 2017; 61:2803. [PMID: 29046057 PMCID: PMC5607851 DOI: 10.4081/ejh.2017.2803] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 08/01/2017] [Accepted: 08/01/2017] [Indexed: 12/27/2022] Open
Abstract
Biliary atresia leads to cirrhosis in the vast majority of patients and constitutes the first cause of paediatric liver transplantation. Animal models allow us to understand the molecular basis and natural history of diseases. The aim of this study is to describe a surgically created animal model of biliary atresia with emphasis in long-term liver function. Forty-two 3-week-old Sprague-Dawley rats were randomly divided into two groups: bile duct ligature (BDL) and control. The animals were sacrificed on the 2nd, 4th, and 6th postoperative weeks. Blood samples were collected for liver function analysis. The spleen to body weight ratio was determined. Histopathological examination of liver tissue was performed by hematoxylin-eosin and Sirius red staining. Collagen quantification was determined by using colorimetric digital image analysis and was expressed as a percentage of total liver tissue area. Quantitative real-time polymerase chain reaction was performed to analyse gene expression levels of transforming growth factor-β1 (Tgfb1) and apeline (Apln) genes. Statistical analysis was performed where P<0.05 was considered significant. Animals from BDL group developed increasing cholestasis with clinical and laboratory features. Splenomegaly was detected at 4th and 6th week (P<0.05). Histological evaluation of the liver showed ductular reaction, portal fibrosis and bile plugs. Collagen area to total liver tissue area had a median of 2.5% in the control group and 6.5 %, 14.3 % and 37.7 % in BDL rats at 2nd, 4th and 6th weeks respectively (P<0.001). Tgfb1 mRNA expression level was significantly higher at 6th week (P<0.001) in BDL group when compared to control. Apln mRNA expression level was significantly higher at 4th and 6th week (P<0.001) and showed a positive linear correlation (r = 0.975, P<0.05) in BDL group when compared to control. Bile duct ligature in young rats is an animal model that recreates clinical, laboratory, histological and molecular findings of biliary atresia. Bile duct ligature constitutes a good animal model to investigate therapeutic approaches for modifying the progression of liver fibrosis in biliary atresia.
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Affiliation(s)
- Matias Garrido
- Universidad de Valparaíso, Centro de Investigaciones Biomédicas.
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Dietzen DJ. Fifty Shades of Yellow. Clin Chem 2017; 63:937-938. [PMID: 28320762 DOI: 10.1373/clinchem.2017.271460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 02/17/2017] [Indexed: 12/12/2022]
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Pediatric cholangiopathies: diseases of the gallbladder and biliary tract. Abdom Radiol (NY) 2017; 42:69-85. [PMID: 27518785 DOI: 10.1007/s00261-016-0865-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Pediatric gallbladder and bile duct disease encompasses a broad spectrum of processes, from congenital to developmental to neoplastic. We describe normal pediatric biliary anatomy and summarize the most common pathologic entities, with a focus on non-invasive imaging techniques and findings. Ultrasound is the first-line imaging modality in children with suspected biliary pathology based on its widespread availability, cost effectiveness, and lack of ionizing radiation. MRI and MRCP are often used for further evaluation in cases of diagnostic uncertainty and for surgical planning.
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Russo P, Magee JC, Anders RA, Bove KE, Chung C, Cummings OW, Finegold MJ, Finn LS, Kim GE, Lovell MA, Magid MS, Melin-Aldana H, Ranganathan S, Shehata BM, Wang L, White FV, Chen Z, Spino C. Key Histopathologic Features of Liver Biopsies That Distinguish Biliary Atresia From Other Causes of Infantile Cholestasis and Their Correlation With Outcome: A Multicenter Study. Am J Surg Pathol 2016; 40:1601-1615. [PMID: 27776008 PMCID: PMC5123664 DOI: 10.1097/pas.0000000000000755] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The liver biopsy guides diagnostic investigation and therapy in infants with undiagnosed cholestasis. Histologic features in the liver may also have prognostic value in the patient with biliary atresia (BA). We assessed the relative value of histologic features in 227 liver needle biopsies in discriminating between BA and other cholestatic disorders in infants enrolled in a prospective Childhood Liver Disease Research Network (ChiLDReN) cohort study by correlating histology with clinical findings in infants with and without BA. In addition, we reviewed 316 liver biopsies from clinically proven BA cases and correlated histologic features with total serum bilirubin 6 months after hepatoportoenterostomy (the Kasai procedure, HPE) and transplant-free survival up to 6 years. Review pathologists were blinded to clinical information except age. Semiquantitative scoring of 26 discrete histologic features was based on consensus. Bile plugs in portal bile ducts/ductules, moderate to marked ductular reaction, and portal stromal edema had the largest odds ratio for predicting BA versus non-BA by logistic regression analysis. The diagnostic accuracy of the needle biopsy was estimated to be 90.1% (95% confidence interval [CI]: 85.2%, 94.9%), whereas sensitivity and specificity for a diagnosis of BA are 88.4% (95% CI: 81.4, 93.5) and 92.7% (95% CI: 84.8, 97.3), respectively. No histologic features were associated with an elevated serum bilirubin 6 months after HPE, although it (an elevated serum bilirubin) was associated with an older age at HPE. Higher stages of fibrosis, a ductal plate configuration, moderate to marked bile duct injury, an older age at HPE, and an elevated international normalized ratio were independently associated with a higher risk of transplantation.
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Affiliation(s)
- P Russo
- Department of Pathology and Laboratory Medicine, the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - JC Magee
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - RA Anders
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - KE Bove
- Division of Pediatric Pathology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - C Chung
- Division of Pathology, The Hospital of Sick Children, Toronto, Canada
| | - OW Cummings
- Department of Pathology, Indiana University School of Medicine, Indianapolis, Indiana
| | - MJ Finegold
- Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - LS Finn
- Department of Pathology, Seattle Children’s Hospital, Seattle, Washington
| | - GE Kim
- Department of Pathology, University of California San Francisco, San Francisco, California
| | - MA Lovell
- Department of Pathology, Children’s Hospital Colorado, Aurora, Colorado
| | - MS Magid
- Department of Pathology, Kravis Children’s Hospital, Mount Sinai Health System, New York, New York
| | - H Melin-Aldana
- Department of Pathology, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | - S Ranganathan
- Department of Pathology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - BM Shehata
- Department of Pathology, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - L Wang
- Department of Pathology, Children’s Hospital Los Angeles, Los Angeles, California
| | - FV White
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
| | - Z Chen
- Quest Diagnostics, Health Informatics, Madison New Jersey
| | - C Spino
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
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Rafeey M, Saboktakin L, Hasani JS, Naghashi S. Diagnostic value of anti-smooth muscle antibodies and liver enzymes in differentiation of extrahepatic biliary atresia and idiopathic neonatal hepatitis. Afr J Paediatr Surg 2016; 13:63-8. [PMID: 27251654 PMCID: PMC4955439 DOI: 10.4103/0189-6725.182558] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND We aimed to evaluate the diagnostic value of anti-smooth muscle antibodies (ASMA) and two liver markers (gamma-glutamyl transpeptidase [GGT] and alkaline phosphatase [ALP]) for differentiating between patients with extrahepatic biliary atresia (EHBA) and idiopathic neonatal hepatitis (INH). MATERIALS AND METHODS During April 2010-2011, all infants at 2 weeks of age who were diagnosed with cholestasis and admitted to Children's Hospital of Tabriz were enrolled. Based on the results of physical examination, laboratory, imaging and pathological studies, neonates were divided into two groups (EHBA and INH). Receiver operating characteristics analysis was used to define sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy for ASMA, GGT and ALP. RESULTS Thirty neonates with cholestasis (18 with EHBA and 12 with INH) and mean age of 54.66 25.86 days were enrolled. Total and direct bilirubin, serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase and ASMA titres were highly not significant (P > 0.05) in patients with INH. GGT (P = 0.008) and ALP (P = 0.01) had statistically significant differences that were higher in patients with EHBA. The sensitivity, specificity, PPV and NPV, accuracy, LR+ and LR- of SMA in differentiating cases with BA were 66.7%, 75%, 80% 60%, 70%, 2.68 and 0.44, respectively. For GGT, the values were 88.9%, 66.7%, 80%, 80%, 79.1%, 3.08 and 0.31, respectively. Finally, for ALP, the values were 77.8%, 75%, 82.4%, 69.2%, 80%, 2.66 and 0.24, respectively. CONCLUSION Our study showed that ASMA may be a useful biomarker for differentiation of EHBA from INH. Further studies with larger samples are recommended for confirming the results of this study.
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Affiliation(s)
- Mandana Rafeey
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Lida Saboktakin
- Department of Pediatrics, Pediatric Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Jamshid Shoa Hasani
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shahnaz Naghashi
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Arafa RS, Abdel Haie OM, El-Azab DS, Abdel-Rahman AM, Sira MM. Significant hepatic expression of IL-2 and IL-8 in biliary atresia compared with other neonatal cholestatic disorders. Cytokine 2016; 79:59-65. [PMID: 26765485 DOI: 10.1016/j.cyto.2015.12.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 12/14/2015] [Accepted: 12/29/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Although the exact etiology of biliary atresia (BA) is still elusive, inflammation plays a key role. Release of proinflammatory cytokines from activated immune cells perpetuates the injury and causes biliary destruction. We aimed to study interleukin (IL)-2 and IL-8 expression in liver tissue of BA patients compared with other neonatal cholestatic disorders. METHODS The study included 59 infants with neonatal cholestasis in two groups; BA group (n=31) and non-BA group (n=28) with cholestatic disorders other than BA as controls. Demographic, clinical, laboratory, and histopathological parameters were collected. IL-2 and IL-8 immunostaining was performed. Immunostaining in portal cellular infiltrate was scored as positive or negative and expressed as the mean cell count in three portal tracts. RESULTS The mean value of IL-2 and IL-8 positive inflammatory cells was significantly higher in BA than in non-BA group (P-values of 0.004 and 0.002 respectively). IL-2 correlated significantly with IL-8 immunostaining in both BA and non-BA group (P<0.0001 for both). Furthermore, both cytokines in both groups correlated significantly with inflammatory activity in liver biopsy while there was no significant correlation with the other studied parameters. Yet, there was a trend of increased expression of IL-2 and IL-8 with increasing stage of fibrosis in BA group. This trend was not observed in non-BA group. CONCLUSION The significantly higher expression of IL-2 and IL-8 in patients with BA compared to non-BA suggests a potential role for these cytokines in the pathogenesis in therapy of this devastating neonatal hepatic disorder.
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Affiliation(s)
- Reda Sanad Arafa
- Department of Pediatrics, Faculty of Medicine, Benha University, Egypt
| | | | - Dina Shehata El-Azab
- Department of Pathology, National Liver Institute, Menofiya University, 32511 Shebin El-koom, Menofiya, Egypt
| | | | - Mostafa M Sira
- Department of Pediatric Hepatology, National Liver Institute, Menofiya University, 32511 Shebin El-koom, Menofiya, Egypt.
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Monti L, Soglia G, Tomà P. Imaging in pediatric liver transplantation. Radiol Med 2016; 121:378-90. [DOI: 10.1007/s11547-016-0628-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 01/31/2016] [Indexed: 12/11/2022]
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Effectiveness of Enteral Versus Oral Nutrition With a Medium-Chain Triglyceride Formula to Prevent Malnutrition and Growth Impairment in Infants With Biliary Atresia. J Pediatr Gastroenterol Nutr 2016. [PMID: 26196199 DOI: 10.1097/mpg.0000000000000909] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of this study was to compare the effectiveness of oral (PO) versus enteral nutrition (EN) medium-chain triglyceride (MCT) containing-formula to prevent malnutrition and growth impairment in infants with biliary atresia (BA) waiting for a liver transplant. METHODS A total of 15 infants, 3 to 9 months old with BA were included. They were randomly assigned to either PO or EN. For 12 weeks, both groups received an MCT formula fortified with glucose polymers and corn oil to reach a caloric density between 0.8 and 1 kcal/mL. The formula given to the PO group was administered ad libitum and that given via EN was infused through a nasogastric tube to reach 140% of the energy intake recommended by the Dietary Recommended Intake guidelines. Protein intake was adjusted to 4 to 5 g/kg present weight. Outcome variables were growth and nutritional status evaluated periodically by anthropometric indicators. Biochemical and hematological variables were evaluated through the study. RESULTS Baseline clinical, nutritional, biochemical, and hematological variables showed no differences between the study groups. Baseline length/age was <-2 SD in 10 of the 15 patients; in the PO group, it fell <-3 SD, whereas in the EN group, it remained stable. Head circumference z score dropped 0.6 SD in the PO group, whereas in the EN group it remained stable. Triceps skinfold values improved in the infants taking EN, P < 0.001. The frequency of adverse effects--respiratory infection and diarrhea--was higher in the EN group. No biochemical or hematological differences were observed between the study groups throughout the study. CONCLUSIONS A 12-week EN trial with an MCT-fortified formula prevented malnutrition and growth impairment in infants with BA waiting for a liver transplant.
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Sira MM, Sira AM, Ehsan NA, Mosbeh A. P-Selectin (CD62P) Expression in Liver Tissue of Biliary Atresia: A New Perspective in Etiopathogenesis. J Pediatr Gastroenterol Nutr 2015; 61:561-7. [PMID: 26102172 DOI: 10.1097/mpg.0000000000000875] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The etiology of biliary atresia (BA) is still elusive. Inflammation plays a key role in bile duct and liver injury. The recruitment and accumulation of inflammatory cells is largely dependent on adhesion molecules. We aimed to investigate P-selectin (CD62P) expression in liver tissue in patients with BA compared with other neonatal cholestatic disorders. METHODS The study included 63 infants with neonatal cholestasis in 2 groups: BA group (n = 32) and non-BA group (n = 31) with non-BA cholestatic disorders as controls. Demographic, clinical, laboratory, ultrasonographic, and histopathological parameters were collected. P-selectin immunostaining was performed. Immunostaining in bile duct epithelium, cellular infiltrate, and vascular endothelial cells were scored as positive or negative. RESULTS The frequency of P-selectin-positive endothelium, platelets, and bile duct epithelium was significantly higher in the BA group (72%, 72%, and 63%, respectively) than in the non-BA group (32%, 16%, and 13%, respectively) with P of 0.002, <0.0001, and <0.0001, respectively. Few mononuclear cellular infiltrates in portal tract expressed P-selectin and were comparable in both groups (P = 0.932). Of interest, the platelet count was significantly higher in the BA group (532 ± 172) than in the non-BA group (406 ± 158), and 68.8% of the BA group had thrombocytosis versus 25% in the controls (P = 0.001 for both). CONCLUSIONS The significant expression of P-selectin in endothelium, platelets, and bile duct epithelium in patients with BA suggests a potential role for this adhesion molecule in the pathogenesis of this devastating neonatal hepatic disorder. It further suggests that platelets in BA are activated and may have a role in the inflammatory process in BA.
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Affiliation(s)
- Mostafa M Sira
- *Department of Pediatric Hepatology †Department of Pathology, National Liver Institute, Menofiya University, Shebin El-koom, Menofiya, Egypt
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Abstract
OBJECTIVES Discrimination of biliary atresia (BA) from other causes of neonatal cholestasis (NC) is challenging. We aimed to analyze the clinicopathological findings in cholestatic infants who were provisionally diagnosed with BA and then excluded by intraoperative cholangiography compared with those with a definitive diagnosis of BA and to shed light on common misdiagnoses of BA. METHODS We retrospectively analyzed the data of infants diagnosed preoperatively with BA and referred to surgery between the years 2009 and 2013. On the basis of intraoperative cholangiography results, infants were divided into those with a definitive diagnosis of BA and those misdiagnosed with BA. RESULTS Out of 147 infants, there was a misdiagnosis of BA in 10 (6.8%) infants. Alanine transaminase was significantly higher in the non-BA group, whereas other clinical and laboratory findings were comparable in both groups. Hepatomegaly and abnormal gallbladder in ultrasound, and ductular proliferation and advanced grades of portal fibrosis in liver biopsy were significantly higher in infants with BA. However, giant cells were more common in the non-BA infants. Nonetheless, the frequency of clay stool, hepatomegaly, abnormal gallbladder, ductular proliferation, and advanced portal fibrosis was remarkable (100, 70, 40, 70, and 50%, respectively) in the misdiagnosed infants. The misdiagnoses were idiopathic neonatal hepatitis, progressive familial intrahepatic cholestasis type 3, cytomegalovirus hepatitis, Alagille syndrome, and a cholangitic form of congenital hepatic fibrosis. CONCLUSION A meticulous preoperative workup should be performed to exclude other causes of NC even if signs of BA are present, especially if features such as giant cells in histopathology are present. This involves completing the NC workup in parallel involving all common causes of NC rather than performing them in series to avoid loss of valuable time and efforts.
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Affiliation(s)
- Mostafa M Sira
- Departments of aPediatric Hepatology bHepatobiliary Surgery, National Liver Institute, Menofiya University, 32511, Shebin El-koom, Menofiya, Egypt
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EXP CLIN TRANSPLANTExp Clin Transplant 2014; 12. [DOI: 10.6002/ect.25liver.p44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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The use of Yes-associated protein expression in the diagnosis of persistent neonatal cholestatic liver disease. Hum Pathol 2014; 45:1057-64. [PMID: 24746211 DOI: 10.1016/j.humpath.2014.01.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 01/06/2014] [Accepted: 01/08/2014] [Indexed: 12/19/2022]
Abstract
Although physiologic jaundice of neonates is common, persistent neonatal cholestasis is life-threatening and has multiple etiologies. Among these etiologies, biliary atresia (BA) requires rapid diagnosis and treatment. In diagnosing BA, the surgical pathologist must recognize subtle histologic changes, often with only a small core liver biopsy. To aid in the differential diagnosis of neonatal cholestasis, we investigated Yes-associated protein (YAP), a regulator of organ size and bile duct development. We examined whether a YAP immunostain can highlight emerging hepatobiliary epithelium in BA (n = 28) versus other causes of persistent cholestasis (non-BA; n = 15) and thus serve as a useful diagnostic marker in persistent neonatal jaundice. We show significantly (P < .01) more high-grade (<2) fibrosis and ductular proliferation among BA versus non-BA cases. Likewise, there was significantly more high-grade (2-3/3) cytoplasmic and nuclear YAP staining in BA (97% and 89%) versus non-BA (20% and 13%). High-grade nuclear YAP staining was both sensitive (88%) and specific (87%) for the diagnosis of BA. In contrast to neonatal cholestasis, the differences in YAP localization in cholestatic/obstructed versus nonobstructed adult livers were not significant. Lastly, we found that pharmacologic inhibition of the YAP complex in both cholangiocyte and cholangiocarcinoma cell lines blocked compensatory bile duct proliferation, an early marker of BA that requires nuclear YAP expression, in a time- and dose-dependent manner. In summary, we show that YAP expression modulates both bile duct proliferation and liver damage/fibrosis while acting as a sensitive and specific marker in the differential diagnosis of persistent neonatal cholestasis.
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Hoerning A, Raub S, Dechêne A, Brosch MN, Kathemann S, Hoyer PF, Gerner P. Diversity of disorders causing neonatal cholestasis - the experience of a tertiary pediatric center in Germany. Front Pediatr 2014; 2:65. [PMID: 25003101 PMCID: PMC4066316 DOI: 10.3389/fped.2014.00065] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 06/01/2014] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Rapidly establishing the cause of neonatal cholestasis is an urgent matter. The aim of this study was to report on the prevalence and mortality of the diverse disorders causing neonatal cholestasis in an academic center in Germany. METHODS Clinical chemistry and cause of disease were retrospectively analyzed in 82 infants (male n = 42, 51%) that had presented with neonatal cholestasis to a tertiary medical center from January 2009 to April 2013. RESULTS Altogether, 19 disorders causing neonatal cholestasis were identified. Biliary atresia was the most common diagnosis (41%), followed by idiopathic cases (13%), progressive familial intrahepatic cholestasis (PFIC, 10%), cholestasis in preterm infants (10%), α1AT deficiency, Alagille syndrome, portocaval shunts, mitochondriopathy, biliary sludge (all 2%), and others. Infants with biliary atresia were diagnosed with a mean age of 62 days, they underwent Kasai portoenterostomy ~66 days after birth. The majority of these children (~70%) received surgery within 10 weeks of age and 27% before 60 days. The 2-year survival with their native liver after Kasai procedure was 12%. The time span between Kasai surgery and liver transplantation was 176 ± 73 days. Six children (7%), of whom three patients had a syndromic and one a non-syndromic biliary atresia, died prior to liver transplantation. The pre- and post-transplant mortality rate for children with biliary atresia was ~12 and ~17%, respectively. CONCLUSION Neonatal cholestasis is a severe threat associated with a high risk of complications in infancy and it therefore requires urgent investigation in order to initiate life saving therapy. Although in the last 20 years new causes such as the PFICs have been identified and newer diagnostic tools have been introduced into the clinical routine biliary atresia still represents the major cause.
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Affiliation(s)
- André Hoerning
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany ; Department of Pediatrics and Adolescent Medicine, University Children's Hospital Erlangen, Friedrich-Alexander University , Erlangen , Germany
| | - Simon Raub
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Michelle N Brosch
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Simone Kathemann
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Peter F Hoyer
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Patrick Gerner
- Department of Pediatrics and Adolescent Medicine, University Children's Hospital , Freiburg , Germany
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Mokhtari M, Kumar PV, Salimi A. A study to demonstrate the use of FNA cytology rather than biopsy in the diagnosis of neonatal biliary atresia. Cytopathology 2013; 25:336-9. [PMID: 24329590 DOI: 10.1111/cyt.12122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To study the use of fine needle aspiration (FNA) cytology in neonatal biliary atresia (BA). METHODS Twelve female and nine male patients (age range, 3-7 months; mean age, 4.5 months) with a pre-operative diagnosis of BA, who were scheduled for Kasia portoenterostomy and selected for intraoperative FNA, were studied. RESULTS Cholestasis, bile deposits, bile infarcts, hepatitic rosettes enclosing bile plugs, feathery degeneration of hepatocytes and inflammatory cells were seen in the cytological slides. Bile infarcts, rosette formation and inflammatory cells were mainly noticed in type 3 BA. Bile infarcts and hepatitic rosettes are surrogate findings for the diagnosis of the obstructive type of cholestasis. CONCLUSION With the help of imaging studies, FNA in a multidisciplinary setting can be diagnostic of neonatal BA when cytological features suggest the obstructive nature of cholestasis, but this procedure cannot replace completely liver biopsy for this diagnosis.
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Affiliation(s)
- M Mokhtari
- Department of Pathology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Ductal plate malformation in patients with biliary atresia. Eur J Pediatr 2012; 171:1799-804. [PMID: 22983023 DOI: 10.1007/s00431-012-1820-7] [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: 06/05/2012] [Accepted: 08/30/2012] [Indexed: 10/27/2022]
Abstract
UNLABELLED The presence of ductal plate malformation (DPM+) on liver histology in children with biliary atresia (BA) is a marker of early intrauterine disease onset and an indication of an unfavorable prognosis. We studied the prognostic value of DPM in infants with BA after hepatoportoenterostomy (HPE). We reviewed 28 BA patients who underwent HPE in a single medical center. We examined the time of jaundice onset after delivery (conjugated hyperbilirubinemia): early onset (fetal phenotype with no jaundice-free interval) vs. late onset (perinatal phenotype with jaundice-free interval) and the presence or absence of DPM (DPM+ or DPM-) histopathology. Primary outcome was jaundice clearance at 3 months after HPE and survival with native liver (SNL). Eight children had fetal and 20 had perinatal BA (8 DPM+, 12 DPM-). At 3 months after HPE, no patients with fetal BA had achieved jaundice clearance, while jaundice clearance was achieved in five patients with DPM+ perinatal disease and four patients with DPM- perinatal BA (P = 0.03, comparing all three groups; P = 0.36, comparing DPM+ vs. DPM- perinatal patients). Median SNL was 8.6 months for fetal BA patients, 148.2 months for DPM+ perinatal BA patients, and 93.2 months for DPM- perinatal BA patients (log-rank test, P < 0.001, comparing all three groups; P = 0.59, comparing DPM+ vs. DPM- perinatal patients). After adjusting for BA type, age older than 2 months at HPE was associated with worse SNL [P = 0.03; hazard ratio = 4.0 (95 % CI, 1.1-14.2)]. CONCLUSIONS Early onset of jaundice, regardless of DPM histology, was the most ominous sign of poor outcome in infants with BA after HPE.
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