1
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Hercun J, Sherker AH. In decompensated cirrhosis, targeted albumin infusions did not improve an in-hospital composite outcome at 15 d. Ann Intern Med 2021; 174:JC91. [PMID: 34339226 DOI: 10.7326/acpj202108170-091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
China L, Freemantle N, Forrest E, et al. A randomized trial of albumin infusions in hospitalized patients with cirrhosis. N Engl J Med. 2021;384:808-17. 33657293.
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Affiliation(s)
- Julian Hercun
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, Maryland, USA (J.H., A.H.S.)
| | - Averell H Sherker
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, Maryland, USA (J.H., A.H.S.)
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2
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Feng S, Bucuvalas JC, Mazariegos GV, Magee JC, Sanchez-Fueyo A, Spain KM, Lesniak A, Kanaparthi S, Perito E, Venkat VL, Burrell BE, Alonso EM, Bridges ND, Doo E, Gupta NA, Himes RW, Ikle D, Jackson AM, Lobritto SJ, Jose Lozano J, Martinez M, Ng VL, Rand EB, Sherker AH, Sundaram SS, Turmelle YP, Wood-Trageser M, Demetris AJ. Efficacy and Safety of Immunosuppression Withdrawal in Pediatric Liver Transplant Recipients: Moving Toward Personalized Management. Hepatology 2021; 73:1985-2004. [PMID: 32786149 DOI: 10.1002/hep.31520] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/13/2020] [Accepted: 07/26/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Tolerance is transplantation's holy grail, as it denotes allograft health without immunosuppression and its toxicities. Our aim was to determine, among stable long-term pediatric liver transplant recipients, the efficacy and safety of immunosuppression withdrawal to identify operational tolerance. APPROACH AND RESULTS We conducted a multicenter, single-arm trial of immunosuppression withdrawal over 36-48 weeks. Liver tests were monitored biweekly (year 1), monthly (year 2), and bimonthly (years 3-4). For-cause biopsies were done at investigators' discretion but mandated when alanine aminotransferase or gamma glutamyltransferase exceeded 100 U/L. All subjects underwent final liver biopsy at trial end. The primary efficacy endpoint was operational tolerance, defined by strict biochemical and histological criteria 1 year after stopping immunosuppression. Among 88 subjects (median age 11 years; 39 boys; 57 deceased donor grafts), 33 (37.5%; 95% confidence interval [CI] 27.4%, 48.5%) were operationally tolerant, 16 were nontolerant by histology (met biochemical but failed histological criteria), and 39 were nontolerant by rejection. Rejection, predicted by subtle liver inflammation in trial entry biopsies, typically (n = 32) occurred at ≤32% of the trial-entry immunosuppression dose and was treated with corticosteroids (n = 32) and/or tacrolimus (n = 38) with resolution (liver tests within 1.5 times the baseline) for all but 1 subject. No death, graft loss, or chronic, severe, or refractory rejection occurred. Neither fibrosis stage nor the expression level of a rejection gene set increased over 4 years for either tolerant or nontolerant subjects. CONCLUSIONS Immunosuppression withdrawal showed that 37.5% of selected pediatric liver-transplant recipients were operationally tolerant. Allograft histology did not deteriorate for either tolerant or nontolerant subjects. The timing and reversibility of failed withdrawal justifies future trials exploring the efficacy, safety, and potential benefits of immunosuppression minimization.
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Affiliation(s)
- Sandy Feng
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - John C Bucuvalas
- Mount Sinai Kravis Children's Hospital and Recanati/Miller Transplantation Institute, Mount Sinai Health System, New York, NY
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - John C Magee
- Section of Transplant Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | | | - Andrew Lesniak
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | | | - Emily Perito
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Veena L Venkat
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | | | - Estella M Alonso
- Siragusa Transplantation Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Nancy D Bridges
- Transplantation Branch, Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, Rockville, MD
| | - Edward Doo
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Nitika A Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Ryan W Himes
- Section of Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX
| | | | | | - Steven J Lobritto
- Center for Liver Diseases and Transplantation, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Juan Jose Lozano
- Bioinformatic Platform, Biomedical Research Center in Hepatic and Digestive Diseases, Instituto de Salud Carlos III, Barcelona, Spain
| | - Mercedes Martinez
- Center for Liver Diseases and Transplantation, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Vicky L Ng
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, OH, Canada
| | - Elizabeth B Rand
- Liver Transplant Program, The Children's Hospital of Pennsylvania, Philadelphia, PA
| | - Averell H Sherker
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Shikha S Sundaram
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Yumirle P Turmelle
- Division of Gastroenterology, Hepatology, and Nutrition, Washington University School of Medicine, St. Louis, MO
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3
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Teckman J, Rosenthal P, Hawthorne K, Spino C, Bass LM, Murray KF, Kerkar N, Magee JC, Karpen S, Heubi JE, Molleston JP, Squires RH, Kamath BM, Guthery SL, Loomes KM, Sherker AH, Sokol RJ. Longitudinal Outcomes in Young Patients with Alpha-1-Antitrypsin Deficiency with Native Liver Reveal that Neonatal Cholestasis is a Poor Predictor of Future Portal Hypertension. J Pediatr 2020; 227:81-86.e4. [PMID: 32663593 PMCID: PMC7686087 DOI: 10.1016/j.jpeds.2020.07.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To identify predictors of portal hypertension, liver transplantation, and death in North American youth with alpha-1-antitrypsin (AAT) deficiency, and compare with patients with AAT deficiency elsewhere. STUDY DESIGN The Childhood Liver Disease Research Network Longitudinal Observational Study of Genetic Causes of Intrahepatic Cholestasis is a prospective, cohort study of pediatric cholestatic liver diseases, including AAT deficiency, enrolling PIZZ and PISZ subjects 0-25 years of age seen since November 2007 at 17 tertiary care centers in the US and Canada. Data from standard-of-care baseline and annual follow-up visits were recorded from medical records, history, physical examination, and laboratory studies. Participants with portal hypertension were identified based on data collected. RESULTS We enrolled 350 participants (60% male) with a native liver; 278 (79%) entered the cohort without portal hypertension and 18 developed portal hypertension during follow-up. Thirty participants required liver transplantation; 2 patients died during 1077 person-years of follow-up. There was no difference in participants with or without preceding neonatal cholestasis progressing to transplantation or death during the study (12% vs 7%; P = .09), or in experiencing portal hypertension (28% vs 21%; P = .16); the hazard ratio for neonatal cholestasis leading to portal hypertension was P = .04. Development of portal hypertension was associated with a reduced height Z-score. CONCLUSIONS Portal hypertension in youth with AAT deficiency impacts growth measures. Progression to liver transplantation is slow and death is rare, but the risk of complications and severe liver disease progression persists throughout childhood. A history of neonatal cholestasis is a weak predictor of severe disease.
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Affiliation(s)
- Jeffrey Teckman
- Pediatrics and Biochemistry, Saint Louis University, Cardinal Glennon Children’s Medical Center, Saint Louis, MO
| | - Philip Rosenthal
- Pediatrics and Surgery, University of California San Francisco, San Francisco, CA
| | | | - Cathie Spino
- Biostatistics, University of Michigan, Ann Arbor, MI
| | - Lee M. Bass
- Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Karen F. Murray
- Pediatric Gastroenterology and Hepatology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Nanda Kerkar
- Pediatric Gastroenterology, Children’s Hospital Los Angeles, Los Angeles, CA
| | - John C. Magee
- Surgery, University of Michigan School of Medicine, Ann Arbor, MI
| | - Saul Karpen
- Pediatrics, Emory University, Children’s Healthcare Atlanta, Atlanta, GA
| | - James E. Heubi
- Pediatric Gastroenterology and Hepatology, Children’s Hospital Medical Center, Cincinnati, OH
| | - Jean P. Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition, James Whitcomb Riley Hospital for Children, Indianapolis, IN
| | | | - Binita M. Kamath
- Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen L. Guthery
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, University of Utah, and Intermountain Primary Children’s Hospital, Salt Lake City, UT
| | - Kathleen M. Loomes
- Pediatric Gastroenterology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Averell H. Sherker
- National Institute of Diabetes, Digestive and Kidney Disease, National Institutes of Health, Baltimore, MD
| | - Ronald J. Sokol
- Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO
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4
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Loomba R, Neuschwander-Tetri BA, Sanyal A, Chalasani N, Diehl AM, Terrault N, Kowdley K, Dasarathy S, Kleiner D, Behling C, Lavine J, Van Natta M, Middleton M, Tonascia J, Sirlin C, Allende D, Dasarathy S, McCullough AJ, Penumatsa R, Dasarathy J, Lavine JE, Abdelmalek MF, Bashir M, Buie S, Diehl AM, Guy C, Kigongo C, Kopping M, Malik D, Piercy D, Chalasani N, Cummings OW, Gawrieh S, Ragozzino L, Sandrasegaran K, Vuppalanchi R, Brunt EM, Cattoor T, Carpenter D, Freebersyser J, King D, Lai J, Neuschwander‐Tetri BA, Siegner J, Stewart S, Torretta S, Wriston K, Gonzalez MC, Davila J, Jhaveri M, Kowdley KV, Mukhtar N, Ness E, Poitevin M, Quist B, Soo S, Ang B, Behling C, Bhatt A, Loomba R, Middleton MS, Sirlin C, Akhter MF, Bass NM, Brandman D, Gill R, Hameed B, Maher J, Terrault N, Ungermann A, Yeh M, Boyett S, Contos MJ, Kirwin S, Luketic VA, Puri P, Sanyal AJ, Schlosser J, Siddiqui MS, Yost‐Schomer L, Brunt EM, Fowler K, Kleiner DE, Doo EC, Hall S, Hoofnagle JH, Robuck PR, Sherker AH, Torrance R, Belt P, Clark JM, Dodge J, Donithan M, Isaacson M, Lazo M, Meinert J, Miriel L, Sharkey EP, Smith J, Smith M, Sternberg A, Tonascia J, Van Natta ML, Wagoner A, Wilson LA, Yamada G, Yates K, Covarrubias Y, Gamst A, Hamilton G, Henderson W, Hooker J, Lavine JE, Loomba R, Middleton MS, Schlein A, Schwimmer JB, Shen W, Sirlin C, Wolfson T. Multicenter Validation of Association Between Decline in MRI-PDFF and Histologic Response in NASH. Hepatology 2020; 72:1219-1229. [PMID: 31965579 PMCID: PMC8055244 DOI: 10.1002/hep.31121] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 12/23/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Emerging data from a single-center study suggests that a 30% relative reduction in liver fat content as assessed by magnetic resonance imaging-proton density fat fraction (MRI-PDFF) from baseline may be associated with histologic improvement in nonalcoholic steatohepatitis (NASH). There are limited multicenter data comparing an active drug versus placebo on the association between the quantity of liver fat reduction assessed by MRI-PDFF and histologic response in NASH. This study aims to examine the association between 30% relative reduction in MRI-PDFF and histologic response in obeticholic acid (OCA) versus placebo-treated patients in the FLINT (farnesoid X receptor ligand obeticholic acid in NASH trial). APPROACH AND RESULTS This is a secondary analysis of the FLINT trial including 78 patients with MRI-PDFF measured before and after treatment along with paired liver histology assessment. Histologic response was defined as a 2-point improvement in nonalcoholic fatty liver disease activity score without worsening of fibrosis. OCA (25 mg orally once daily) was better than placebo in improving MRI-PDFF by an absolute difference of -3.4% (95% confidence interval [CI], -6.5 to -0.2%, P value = 0.04) and relative difference of -17% (95% CI, -34 to 0%, P value = 0.05). The optimal cutoff point for relative decline in MRI-PDFF for histologic response was 30% (using Youden's index). The rate of histologic response in those who achieved less than 30% decline in MRI-PDFF versus those who achieved a 30% or greater decline in MRI-PDFF (MRI-PDFF responders) relative to baseline was 19% versus 50%, respectively. Compared with MRI-PDFF nonresponders, MRI-PDFF responders demonstrated both a statistically and clinically significant higher odds 4.86 (95% CI, 1.4-12.8, P value < 0.009) of histologic response, including significant improvements in both steatosis and ballooning. CONCLUSION OCA was better than placebo in reducing liver fat. This multicenter trial provides data regarding the association between 30% decline in MRI-PDFF relative to baseline and histologic response in NASH.
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Affiliation(s)
- Rohit Loomba
- University of California San Diego, La Jolla, CA, USA
| | | | - Arun Sanyal
- Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Norah Terrault
- University of California San Francisco, San Francisco, CA USA
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5
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Siegel MJ, Freeman AJ, Ye W, Palermo JJ, Molleston JP, Paranjape SM, Stoll J, Leung D, Masand P, Karmazyn B, Harned R, Ling SC, Navarro OM, Karnsakul W, Alazraki A, Schwarzenberg SJ, Seidel FG, Towbin A, Alonso EM, Nicholas JL, Murray KF, Otto RK, Sherker AH, Magee JC, Narkewicz MR. Heterogeneous Liver on Research Ultrasound Identifies Children with Cystic Fibrosis at High Risk of Advanced Liver Disease: Interim Results of a Prospective Observational Case-Controlled Study. J Pediatr 2020; 219:62-69.e4. [PMID: 32061406 PMCID: PMC7096278 DOI: 10.1016/j.jpeds.2019.12.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/21/2019] [Accepted: 12/13/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess if a heterogeneous pattern on research liver ultrasound examination can identify children at risk for advanced cystic fibrosis (CF) liver disease. STUDY DESIGN Planned 4-year interim analysis of a 9-year multicenter, case-controlled cohort study (Prospective Study of Ultrasound to Predict Hepatic Cirrhosis in CF). Children with pancreatic insufficient CF aged 3-12 years without known cirrhosis, Burkholderia species infection, or short bowel syndrome underwent a screening research ultrasound examination. Participants with a heterogeneous liver ultrasound pattern were matched (by age, Pseudomonas infection status, and center) 1:2 with participants with a normal pattern. Clinical status and laboratory data were obtained annually and research ultrasound examinations biannually. The primary end point was the development of a nodular research ultrasound pattern, a surrogate for advanced CF liver disease. RESULTS There were 722 participants who underwent screening research ultrasound examination, of which 65 were heterogeneous liver ultrasound pattern and 592 normal liver ultrasound pattern. The final cohort included 55 participants with a heterogeneous liver ultrasound pattern and 116 participants with a normal liver ultrasound pattern. All participants with at least 1 follow-up research ultrasound were included. There were no differences in age or sex between groups at entry. Alanine aminotransferase (42 ± 22 U/L vs 32 ± 19 U/L; P = .0033), gamma glutamyl transpeptidase (36 ± 34 U/L vs 15 ± 8 U/L; P < .001), and aspartate aminotransferase to platelet ratio index (0.7 ± 0.5 vs 0.4 ± 0.2; P < .0001) were higher in participants with a heterogeneous liver ultrasound pattern compared with participants with a normal liver ultrasound pattern. Participants with a heterogeneous liver ultrasound pattern had a 9.1-fold increased incidence (95% CI, 2.7-30.8; P = .0004) of nodular pattern vs a normal liver ultrasound pattern (23% in heterogeneous liver ultrasound pattern vs 2.6% in normal liver ultrasound pattern). CONCLUSIONS Research liver ultrasound examinations can identify children with CF at increased risk for developing advanced CF liver disease.
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Affiliation(s)
- Marilyn J Siegel
- Mallinckrodt Institute of Radiology, Washington
University School of Medicine, St Louis, MO
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and
Nutrition, Emory University School of Medicine, Atlanta, GA
| | - Wen Ye
- Department of Biostatistics, University of Michigan
Medical School, Ann Arbor, MI
| | - Joseph J Palermo
- Division of Pediatric Gastroenterology, Hepatology and
Nutrition, Cincinnati Children’s Hospital Medical Center, and Department of
Pediatrics, University of Cincinnati College of Medicine, Cincinnati OH
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition,
Riley Hospital for Children, Indiana University School of Medicine, Indianapolis,
IN
| | - Shruti M Paranjape
- Division of Pediatric Pulmonology, John Hopkins School of
Medicine, Baltimore, MD
| | - Janis Stoll
- Division of Gastroenterology and Nutrition, Washington
University School of Medicine, St Louis, MO
| | - Daniel Leung
- Division of Gastroenterology, Hepatology and Nutrition,
Texas Children’s Hospital, Houston TX
| | - Prakash Masand
- Division of Radiology, Texas Children’s Hospital,
Houston TX
| | - Boaz Karmazyn
- Pediatric Radiology, Riley Hospital for Children,
Indianapolis, IN
| | - Roger Harned
- Division of Pediatric Radiology, Children’s
Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | - Simon C Ling
- Division of Gastroenterology, Hepatology and Nutrition,
The Hospital for Sick Children, Department of Paediatrics, University of Toronto,
Toronto, Ontario, Canada
| | - Oscar M Navarro
- Department of Medical Imaging, University of Toronto,
Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario,
Canada
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Hepatology and
Nutrition, John Hopkins School of Medicine, Baltimore, MD
| | - Adina Alazraki
- Department of Radiology, Emory University School of
Medicine and Children’s Healthcare of Atlanta, Egleston, Atlanta, GA
| | - Sarah Jane Schwarzenberg
- Pediatric Gastroenterology, University of Minnesota
Masonic Children’s Hospital, Minneapolis, MN
| | - F Glen Seidel
- Pediatric Radiology, Lucile Packard Children’s
Hospital, Stanford, CA
| | - Alex Towbin
- Department of Radiology, Cincinnati Children’s
Hospital Medical Center and Department of Radiology, University of Cincinnati
College of Medicine Cincinnati OH
| | - Estella M Alonso
- Division of Pediatric Gastroenterology, Hepatology and
Nutrition, Ann & Robert H. Lurie Children’s Hospital, Chicago IL
| | - Jennifer L. Nicholas
- Mallinckrodt Institute of Radiology, Washington
University School of Medicine, St Louis, MO
| | - Karen F Murray
- Division of Gastroenterology and Hepatology, University
of Washington and Seattle Children’s Hospital, Seattle, WA
| | - Randolph K Otto
- Department of Radiology, Seattle Children’s
Hospital, Seattle, WA
| | | | - John C Magee
- Department of Surgery, University of Michigan Medical
School, Ann Arbor, MI
| | - Michael R Narkewicz
- Digestive Health Institute, Children's Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
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Oketch-Rabah HA, Roe AL, Rider CV, Bonkovsky HL, Giancaspro GI, Navarro V, Paine MF, Betz JM, Marles RJ, Casper S, Gurley B, Jordan SA, He K, Kapoor MP, Rao TP, Sherker AH, Fontana RJ, Rossi S, Vuppalanchi R, Seeff LB, Stolz A, Ahmad J, Koh C, Serrano J, Low Dog T, Ko R. United States Pharmacopeia (USP) comprehensive review of the hepatotoxicity of green tea extracts. Toxicol Rep 2020; 7:386-402. [PMID: 32140423 PMCID: PMC7044683 DOI: 10.1016/j.toxrep.2020.02.008] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/04/2020] [Accepted: 02/12/2020] [Indexed: 02/07/2023] Open
Abstract
As part of the United States Pharmacopeia's ongoing review of dietary supplement safety data, a new comprehensive systematic review on green tea extracts (GTE) has been completed. GTEs may contain hepatotoxic solvent residues, pesticide residues, pyrrolizidine alkaloids and elemental impurities, but no evidence of their involvement in GTE-induced liver injury was found during this review. GTE catechin profiles vary significantly with manufacturing processes. Animal and human data indicate that repeated oral administration of bolus doses of GTE during fasting significantly increases bioavailability of catechins, specifically EGCG, possibly involving saturation of first-pass elimination mechanisms. Toxicological studies show a hepatocellular pattern of liver injury. Published adverse event case reports associate hepatotoxicity with EGCG intake amounts from 140 mg to ∼1000 mg/day and substantial inter-individual variability in susceptibility, possibly due to genetic factors. Based on these findings, USP included a cautionary labeling requirement in its Powdered Decaffeinated Green Tea Extract monograph that reads as follows: "Do not take on an empty stomach. Take with food. Do not use if you have a liver problem and discontinue use and consult a healthcare practitioner if you develop symptoms of liver trouble, such as abdominal pain, dark urine, or jaundice (yellowing of the skin or eyes)."
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Key Words
- ADME, Absorption, distribution, metabolism, and excretion
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- AUC, area under the curve
- Bw, body weight
- C, Catechin
- CAM, causality assessment method
- CG, (+)‐catechin‐3‐gallate
- CIH, Concanavalin A-induced hepatitis
- CMC, chemistry, manufacturing, and controls
- COMT, catechol‐O‐methyltransferase
- Camellia sinensis
- ConA, Concanavalin A
- DILI, drug‐induced liver injury
- DILIN, Drug‐Induced Liver Injury Network
- DO, Diversity Outbred
- DS, Dietary Supplement
- DSAE, JS3 USP Dietary Supplements Admission Evaluations Joint Standard-Setting Subcommittee
- Dietary supplements
- EC, (–)‐epicatechin
- ECG, (‐)‐epicatechin‐3‐gallate
- EFSA, European Food Safety Authority
- EGC, (–)‐epigallocatechin
- EGCG, (–)‐epigallocatechin‐3‐gallate
- FDA, United States Food and Drug Administration
- GC, (+)‐gallocatechin
- GCG, (–)‐gallocatechin‐3‐gallate
- GT(E), green tea or green tea extract
- GT, green tea
- GTE, green tea extract
- GTEH, EP Green Tea Extract Hepatotoxicity Expert Panel
- Green tea
- Green tea extract
- HDS, herbal dietary supplement
- HPMC, Hydroxypropyl methylcellulose
- Hepatotoxicity
- LD50, lethal dose, median
- LFT(s), liver function test(s)
- LT(s), Liver test(s)
- Liver injury
- MGTT, Minnesota Green Tea Trial
- MIDS, multi-ingredient dietary supplement
- MRL, maximum residue limit
- NAA, N-acetyl aspartate
- NIDDK, National Institute of Diabetes and Digestive and Kidney Diseases
- NIH, National Institutes of Health
- NOAEL, no observed adverse effect level
- NTP, National Toxicology Program
- OSM, online supplementary material
- PAs, Pyrrolizidine Alkaloids
- PD-1, Programmed death domain-1
- PDGTE, powdered decaffeinated green tea extract
- PK/PD, pharmacokinetics and pharmacodynamics
- RUCAM, Roussel Uclaf Causality Assessment Method
- SIDS, single-ingredient dietary supplement
- TGF-beta, Transforming growth factor beta
- USP, United States Pharmacopeia
- γ-GT, Gamma-glutamyl transferase
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Affiliation(s)
- Hellen A. Oketch-Rabah
- U.S. Pharmacopeial Convention, Rockville, MD, USA
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
| | - Amy L. Roe
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
- Vice Chair, (USP GTEH EP, 2015-2020 cycle)
| | - Cynthia V. Rider
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
| | - Herbert L. Bonkovsky
- U.S. FDA Liaison to the USP GTEH EP (2015-2020 cycle)
- Section on Gastroenterology & Hepatology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA
| | - Gabriel I. Giancaspro
- U.S. Pharmacopeial Convention, Rockville, MD, USA
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
| | - Victor Navarro
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
- Expert Members of the Drug Induced Liver Injury Network (DILIN), USA
| | - Mary F. Paine
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Joseph M. Betz
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
| | - Robin J. Marles
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
| | - Steven Casper
- U.S. FDA Liaison to the USP GTEH EP (2015-2020 cycle)
| | - Bill Gurley
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
| | - Scott A. Jordan
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
| | - Kan He
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
| | - Mahendra P. Kapoor
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
| | - Theertham P. Rao
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
| | - Averell H. Sherker
- Expert Members of the Drug Induced Liver Injury Network (DILIN), USA
- Liver Diseases Research Branch National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 6707 Democracy Blvd., Bethesda, MD, USA
| | - Robert J. Fontana
- Expert Members of the Drug Induced Liver Injury Network (DILIN), USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Simona Rossi
- Expert Members of the Drug Induced Liver Injury Network (DILIN), USA
| | | | - Leonard B. Seeff
- Expert Members of the Drug Induced Liver Injury Network (DILIN), USA
| | - Andrew Stolz
- Expert Members of the Drug Induced Liver Injury Network (DILIN), USA
| | - Jawad Ahmad
- Expert Members of the Drug Induced Liver Injury Network (DILIN), USA
| | - Christopher Koh
- Expert Members of the Drug Induced Liver Injury Network (DILIN), USA
- Liver Diseases Branch, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, 10 Center Drive, Building 10, Rm 9B-16, Bethesda, MD, 20892,USA
| | - Jose Serrano
- Expert Members of the Drug Induced Liver Injury Network (DILIN), USA
- Liver Diseases Research Branch National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 6707 Democracy Blvd., Bethesda, MD, USA
| | - Tieraona Low Dog
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
| | - Richard Ko
- United States Pharmacopeia Green Tea Hepatotoxicity Expert Panel (USP GTEH EP, 2015-2020 cycle), Rockville, MD, USA
- Chair (USP GTEH EP, 2015-2020 cycle)
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7
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Berauer JP, Mezina AI, Okou DT, Sabo A, Muzny DM, Gibbs RA, Hegde MR, Chopra P, Cutler DJ, Perlmutter DH, Bull LN, Thompson RJ, Loomes KM, Spinner NB, Rajagopalan R, Guthery SL, Moore B, Yandell M, Harpavat S, Magee JC, Kamath BM, Molleston JP, Bezerra JA, Murray KF, Alonso EM, Rosenthal P, Squires RH, Wang KS, Finegold MJ, Russo P, Sherker AH, Sokol RJ, Karpen SJ. Identification of Polycystic Kidney Disease 1 Like 1 Gene Variants in Children With Biliary Atresia Splenic Malformation Syndrome. Hepatology 2019; 70:899-910. [PMID: 30664273 PMCID: PMC6642859 DOI: 10.1002/hep.30515] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 01/02/2019] [Indexed: 12/23/2022]
Abstract
Biliary atresia (BA) is the most common cause of end-stage liver disease in children and the primary indication for pediatric liver transplantation, yet underlying etiologies remain unknown. Approximately 10% of infants affected by BA exhibit various laterality defects (heterotaxy) including splenic abnormalities and complex cardiac malformations-a distinctive subgroup commonly referred to as the biliary atresia splenic malformation (BASM) syndrome. We hypothesized that genetic factors linking laterality features with the etiopathogenesis of BA in BASM patients could be identified through whole-exome sequencing (WES) of an affected cohort. DNA specimens from 67 BASM subjects, including 58 patient-parent trios, from the National Institute of Diabetes and Digestive and Kidney Diseases-supported Childhood Liver Disease Research Network (ChiLDReN) underwent WES. Candidate gene variants derived from a prespecified set of 2,016 genes associated with ciliary dysgenesis and/or dysfunction or cholestasis were prioritized according to pathogenicity, population frequency, and mode of inheritance. Five BASM subjects harbored rare and potentially deleterious biallelic variants in polycystic kidney disease 1 like 1 (PKD1L1), a gene associated with ciliary calcium signaling and embryonic laterality determination in fish, mice, and humans. Heterozygous PKD1L1 variants were found in 3 additional subjects. Immunohistochemical analysis of liver from the one BASM subject available revealed decreased PKD1L1 expression in bile duct epithelium when compared to normal livers and livers affected by other noncholestatic diseases. Conclusion: WES identified biallelic and heterozygous PKD1L1 variants of interest in 8 BASM subjects from the ChiLDReN data set; the dual roles for PKD1L1 in laterality determination and ciliary function suggest that PKD1L1 is a biologically plausible, cholangiocyte-expressed candidate gene for the BASM syndrome.
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Affiliation(s)
- John-Paul Berauer
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Emory University School of Medicine and Children’s Healthcare of Atlanta; Atlanta, GA, 30322, USA
| | - Anya I. Mezina
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Emory University School of Medicine and Children’s Healthcare of Atlanta; Atlanta, GA, 30322, USA
| | - David T. Okou
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Emory University School of Medicine and Children’s Healthcare of Atlanta; Atlanta, GA, 30322, USA
| | - Aniko Sabo
- Human Genome Sequencing Center; Baylor College of Medicine; Houston, TX, 77030, USA
| | - Donna M. Muzny
- Human Genome Sequencing Center; Baylor College of Medicine; Houston, TX, 77030, USA
| | - Richard A. Gibbs
- Human Genome Sequencing Center; Baylor College of Medicine; Houston, TX, 77030, USA
| | - Madhuri R. Hegde
- Department of Human Genetics; Emory University School of Medicine; Atlanta, GA, 30322, USA
| | - Pankaj Chopra
- Department of Human Genetics; Emory University School of Medicine; Atlanta, GA, 30322, USA
| | - David J. Cutler
- Department of Human Genetics; Emory University School of Medicine; Atlanta, GA, 30322, USA
| | - David H. Perlmutter
- Department of Pediatrics; Washington University School of Medicine; St. Louis, MO, 63110, USA
| | - Laura N. Bull
- Department of Medicine; Institute for Human Genetics, and Liver Center Laboratory, University of California San Francisco; San Francisco, CA, 94143, USA
| | | | - Kathleen M. Loomes
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Perelman School of Medicine at the University of Pennsylvania and Children’s Hospital of Philadelphia; Philadelphia, PA 19104, USA
| | - Nancy B. Spinner
- Department of Pathology and Laboratory Medicine; Division of Genomic Diagnostics; Children’s Hospital of Philadelphia; Philadelphia PA, 19104, USA
| | - Ramakrishnan Rajagopalan
- Department of Pathology and Laboratory Medicine; Division of Genomic Diagnostics; Children’s Hospital of Philadelphia; Philadelphia PA, 19104, USA
- Department of Biomedical and Health Informatics; Children’s Hospital of Philadelphia; Philadelphia PA, 19104, USA
| | - Stephen L. Guthery
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; University of Utah; and Intermountain Primary Children’s Hospital Salt Lake City, UT, 84112, USA
| | - Barry Moore
- Department of Human Genetics; University of Utah; Salt Lake City, UT, 84112, USA
| | - Mark Yandell
- Department of Human Genetics; University of Utah; Salt Lake City, UT, 84112, USA
| | - Sanjiv Harpavat
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Baylor College of Medicine; Houston, TX, 77030, USA
| | - John C. Magee
- University of Michigan Medical School; Ann Arbor, MI, 48103, USA
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology and Nutrition; Hospital for Sick Children and University of Toronto; Toronto, ON, M5G 1X8, Canada
| | - Jean P. Molleston
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Indiana University School of Medicine and Riley Hospital for Children; Indianapolis, IN, 46202, USA
| | - Jorge A. Bezerra
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Cincinnati Children’s Hospital Medical Center; Cincinnati, OH, 45229, USA
| | - Karen F. Murray
- Department of Pediatrics; Division of Gastroenterology and Hepatology; University of Washington School of Medicine and Seattle Children’s Hospital; Seattle, WA, 98105, USA
| | - Estella M. Alonso
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Ann and Robert H. Lurie Children’s Hospital of Chicago; Chicago, IL, 60611, USA
| | - Philip Rosenthal
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; University of California San Francisco; San Francisco, CA, 94143, USA
| | - Robert H. Squires
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Children’s Hospital of Pittsburgh of UPMC; Pittsburgh, PA, 15224, USA
| | - Kasper S. Wang
- Department of Surgery; Division of Pediatric Surgery; Children’s Hospital of Los Angeles; University of Southern California; Los Angeles, CO, 90027, USA
| | - Milton J. Finegold
- Department of Pediatrics; Department of Molecular and Cellular Biology; Baylor College of Medicine; Houston, TX, 77030, USA
| | - Pierre Russo
- Department of Pathology and Laboratory Medicine; Children’s Hospital of Philadelphia; Philadelphia PA, 19104, USA
| | - Averell H. Sherker
- Liver Diseases Research Branch; National Institute of Diabetes and Digestive and Kidney Diseases; National Institutes of Health; Bethesda, MD, 20892, USA
| | - Ronald J. Sokol
- Department of Pediatrics; Section of Gastroenterology, Hepatology and Nutrition; Children’s Hospital Colorado and University of Colorado School of Medicine; Aurora, CO, 80045, USA
| | - Saul J. Karpen
- Department of Pediatrics; Division of Gastroenterology, Hepatology and Nutrition; Emory University School of Medicine and Children’s Healthcare of Atlanta; Atlanta, GA, 30322, USA
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8
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Kim S, Moore J, Alonso E, Bednarek J, Bezerra JA, Goodhue C, Karpen SJ, Loomes KM, Magee JC, Ng VL, Sherker AH, Smith C, Spino C, Venkat V, Wang K, Sokol RJ, Mack CL. Correlation of Immune Markers With Outcomes in Biliary Atresia Following Intravenous Immunoglobulin Therapy. Hepatol Commun 2019; 3:685-696. [PMID: 31061956 PMCID: PMC6492477 DOI: 10.1002/hep4.1332] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/11/2019] [Indexed: 12/13/2022] Open
Abstract
Biliary atresia is a progressive fibroinflammatory cholangiopathy of infancy that is associated with activation of innate and adaptive immune responses targeting bile ducts. A recently completed multicenter phase I/IIA trial of intravenous immunoglobulin in biliary atresia did not improve serum total bilirubin levels at 90 days after hepatoportoenterostomy or survival with the native liver at 1 year. A mechanistic aim of this trial was to determine if the peripheral blood immunophenotype was associated with clinical outcomes. Flow cytometry of peripheral blood cell markers (natural killer [NK], macrophage subsets, T‐ and B‐cell subsets, regulatory T cells), neutrophils, and activation markers (clusters of differentiation [CD]38, CD69, CD86, human leukocyte antigen‐DR isotype [HLA‐DR]) was performed on 29 patients with biliary atresia at baseline and at 60, 90, 180, and 360 days after hepatoportoenterostomy. Plasma cytokines and neutrophil products were also measured. Spearman correlations of change of an immune marker from baseline to day 90 with change in serum bilirubin revealed that an increase in total bilirubin correlated with 1) increased percentage of HLA‐DR+CD38+ NK cells and expression of NK cell activation markers CD69 and HLA‐DR, 2) decreased percentage of regulatory T cells, and 3) increased interleukin (IL)‐8 and associated neutrophil products (elastase and neutrophil extracellular traps). Cox modeling revealed that the change from baseline to day 60 of the percentage of HLA‐DR+CD38+ NK cells and plasma IL‐8 levels was associated with an increased risk of transplant or death by day 360. Conclusion: Poor outcomes in biliary atresia correlated with higher peripheral blood NK cells and IL‐8 and lower regulatory T cells. Future studies should include immunotherapies targeting these pathways in order to protect the biliary tree from ongoing damage.
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Affiliation(s)
| | | | - Estella Alonso
- Ann and Robert H. Lurie Children's Hospital of Chicago Chicago IL
| | | | | | | | | | | | | | - Vicky L Ng
- The Hospital for Sick Children, University of Toronto Toronto Canada
| | - Averell H Sherker
- National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases Bethesda MD
| | | | | | | | - Kasper Wang
- Children's Hospital Los Angeles Los Angeles CA
| | - Ronald J Sokol
- Children's Hospital Colorado, University of Colorado School of Medicine Aurora CO
| | - Cara L Mack
- Children's Hospital Colorado, University of Colorado School of Medicine Aurora CO
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9
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Loomes KM, Spino C, Goodrich NP, Hangartner TN, Marker AE, Heubi JE, Kamath BM, Shneider BL, Rosenthal P, Hertel PM, Karpen SJ, Molleston JP, Murray KF, Schwarz KB, Squires RH, Teckman J, Turmelle YP, Alonso EM, Sherker AH, Magee JC, Sokol RJ. Bone Density in Children With Chronic Liver Disease Correlates With Growth and Cholestasis. Hepatology 2019; 69:245-257. [PMID: 30063078 PMCID: PMC6324969 DOI: 10.1002/hep.30196] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 07/24/2018] [Indexed: 12/13/2022]
Abstract
Osteopenia and bone fractures are significant causes of morbidity in children with cholestatic liver disease. Dual-energy X-ray absorptiometry (DXA) analysis was performed in children with intrahepatic cholestatic diseases who were enrolled in the Longitudinal Study of Genetic Causes of Intrahepatic Cholestasis in the Childhood Liver Disease Research Network. DXA was performed on participants aged >5 years (with native liver) diagnosed with bile acid synthetic disorder (BASD), alpha-1 antitrypsin deficiency (A1AT), chronic intrahepatic cholestasis (CIC), and Alagille syndrome (ALGS). Weight, height, and body mass index Z scores were lowest in CIC and ALGS. Total bilirubin (TB) and serum bile acids (SBA) were highest in ALGS. Bone mineral density (BMD) and bone mineral content (BMC) Z scores were significantly lower in CIC and ALGS than in BASD and A1AT (P < 0.001). After anthropometric adjustment, bone deficits persisted in CIC but were no longer noted in ALGS. In ALGS, height-adjusted and weight-adjusted subtotal BMD and BMC Z scores were negatively correlated with TB (P < 0.001) and SBA (P = 0.02). Mean height-adjusted and weight-adjusted subtotal BMC Z scores were lower in ALGS participants with a history of bone fractures. DXA measures did not correlate significantly with biliary diversion status. Conclusion: CIC patients had significant bone deficits that persisted after adjustment for height and weight and generally did not correlate with degree of cholestasis. In ALGS, low BMD and BMC reference Z scores were explained by poor growth. Anthropometrically adjusted DXA measures in ALGS correlate with markers of cholestasis and bone fracture history. Reduced bone density in this population is multifactorial and related to growth, degree of cholestasis, fracture vulnerability, and contribution of underlying genetic etiology.
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Affiliation(s)
- Kathleen M. Loomes
- Division of GI, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Thomas N. Hangartner
- Department of Biomedical, Industrial & Human Factors Engineering, Wright State University, Dayton, OH
| | - Amanda E. Marker
- Department of Biomedical, Industrial & Human Factors Engineering, Wright State University, Dayton, OH
| | - James E. Heubi
- Division of GI, Hepatology and Nutrition, Cincinnati Children’s Medical Center, Cincinnati, OH
| | - Binita M. Kamath
- Division of GI, Hepatology and Nutrition, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Benjamin L. Shneider
- Division of Pediatric GI, Hepatology and Nutrition, Baylor College of Medicine, Houston, TX
| | - Philip Rosenthal
- Division of GI, Hepatology and Nutrition, UCSF, San Francisco, CA
| | - Paula M. Hertel
- Division of Pediatric GI, Hepatology and Nutrition, Baylor College of Medicine, Houston, TX
| | - Saul J. Karpen
- Division of GI, Hepatology and Nutrition, Emory University SOM, Atlanta, GA
| | - Jean P. Molleston
- Division of GI, Hepatology and Nutrition, Indiana University, Riley Hospital for Children, Indianapolis, IN
| | - Karen F. Murray
- Division of GI and Hepatology, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle, WA
| | | | - Robert H. Squires
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Pittsburgh School of Medicine
| | - Jeffrey Teckman
- Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Saint Louis University School of Medicine
| | | | | | | | - John C. Magee
- Department of Surgery, University of Michigan SOM, Ann Arbor, MI
| | - Ronald J. Sokol
- Section of Pediatric GI, Hepatology and Nutrition, Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
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10
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Feng S, Bucuvalas JC, Demetris AJ, Burrell BE, Spain KM, Kanaparthi S, Magee JC, Ikle D, Lesniak A, Lozano JJ, Alonso EM, Bray RA, Bridges NE, Doo E, Gebel HM, Gupta NA, Himes RW, Jackson AM, Lobritto SJ, Mazariegos GV, Ng VL, Rand EB, Sherker AH, Sundaram S, Turmelle YP, Sanchez-Fueyo A. Evidence of Chronic Allograft Injury in Liver Biopsies From Long-term Pediatric Recipients of Liver Transplants. Gastroenterology 2018; 155:1838-1851.e7. [PMID: 30144432 PMCID: PMC6279538 DOI: 10.1053/j.gastro.2018.08.023] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 07/26/2018] [Accepted: 08/08/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS A substantial proportion of pediatric liver transplant recipients develop subclinical chronic allograft injury. We studied whether there are distinct patterns of injury based on histopathologic features and identified associated immunologic profiles. METHODS We conducted a cross-sectional study of 157 stable, long-term pediatric recipients of transplanted livers (70 boys; > 6 years old at time of transplantation; mean, 8.9 ± 3.46 years after liver transplantation) who underwent liver biopsy analysis from August 13, 2012, through May 1, 2014. Participants had received livers from a living or deceased donor and had consistently normal results from liver tests. Liver biopsy specimens were scored by a central pathologist; an unsupervised hierarchical cluster analysis of histologic features was used to sort biopsy samples into 3 clusters. We conducted transcriptional and cytometric analyses of liver tissue samples and performed a systems biology analysis that incorporated clinical, serologic, histologic, and transcriptional data. RESULTS The mean level of alanine aminotransferase in participants was 27.6 ± 14.57 U/L, and the mean level of γ-glutamyl transferase was 17.4 ± 7.93 U/L. Cluster 1 was characterized by interface activity (n = 34), cluster 2 was characterized by periportal or perivenular fibrosis without interface activity (n = 45), and cluster 3 had neither feature (n = 78). We identified a module of genes whose expression correlated with levels of alanine aminotransferase, class II donor-specific antibody, portal inflammation, interface activity, perivenular inflammation, portal and perivenular fibrosis, and cluster assignment. The module was enriched in genes that regulate T-cell-mediated rejection (TCMR) of liver and other transplanted organs. Functional pathway analysis showed overrepresentation of TCMR gene sets for cluster 1 but not clusters 2 or 3. CONCLUSION In an analysis of biopsies from an apparently homogeneous group of stable, long-term pediatric liver transplant recipients with consistently normal liver test results, we found evidence of chronic graft injury (inflammation and/or fibrosis). Biopsy samples with interface activity had a gene expression pattern associated with TCMR.
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Affiliation(s)
- Sandy Feng
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, California.
| | - John C. Bucuvalas
- Pediatric Liver Care Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | | | | | | | - John C. Magee
- Section of Transplant Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Andrew Lesniak
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - Juan J. Lozano
- Biomedical Research Center in Hepatic and Digestive Diseases, Carlos III Health Institute, Barcelona, Spain
| | - Estella M. Alonso
- Siragusa Transplantation Center, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Robert A. Bray
- Department of Pathology, Emory University Hospital, Atlanta, GA
| | - Nancy E. Bridges
- Transplantation Branch; Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, Rockville, MD
| | - Edward Doo
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD; Department of Pathology, Emory University Hospital, Atlanta, GA
| | - Howard M. Gebel
- Department of Pathology, Emory University Hospital, Atlanta, GA
| | - Nitika A. Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Ryan W. Himes
- Section of Gastroenterology, Hepatology, and Nutrition, Texas Children’s Hospital, Houston, TX
| | - Annette M. Jackson
- Division of Immunogenetics and Transplantation Immunology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Steven J. Lobritto
- Center for Liver Diseases and Transplantation, Department of Surgery, Columbia University Medical Center, New York, NY
| | - George V. Mazariegos
- Hillman Center for Pediatric Transplantation, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Vicky L. Ng
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Center, Toronto, Ontario, Canada
| | - Elizabeth B. Rand
- Liver Transplant Program, The Children’s Hospital of Pennsylvania, Philadelphia, PA
| | - Averell H. Sherker
- Siragusa Transplantation Center, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Shikha Sundaram
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Yumirle P. Turmelle
- Division of Gastroenterology, Hepatology, and Nutrition, St. Louis Children’s Hospital, St. Louis, MO
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11
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Alonso EM, Ye W, Hawthorne K, Venkat V, Loomes KM, Mack CL, Hertel PM, Karpen SJ, Kerkar N, Molleston JP, Murray KF, Romero R, Rosenthal P, Schwarz KB, Shneider BL, Suchy FJ, Turmelle YP, Wang KS, Sherker AH, Sokol RJ, Bezerra JA, Magee JC. Impact of Steroid Therapy on Early Growth in Infants with Biliary Atresia: The Multicenter Steroids in Biliary Atresia Randomized Trial. J Pediatr 2018; 202:179-185.e4. [PMID: 30244988 PMCID: PMC6365098 DOI: 10.1016/j.jpeds.2018.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/06/2018] [Accepted: 07/02/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To investigate the impact of corticosteroid therapy on the growth of participants in the Steroids in Biliary Atresia Randomized Trial (START) conducted through the Childhood Liver Disease Research Network. The primary analysis in START indicated that steroids did not have a beneficial effect on drainage in a cohort of infants with biliary atresia. We hypothesized that steroids would have a detrimental effect on growth in these infants. STUDY DESIGN A total of 140 infants were enrolled in START, with 70 randomized to each treatment arm: steroid and placebo. Length, weight, and head circumference were obtained at baseline and follow-up visits to 24 months of age. RESULTS Patients treated with steroids had significantly lower length and head circumference z scores during the first 3 months post-hepatoportoenterostomy (HPE), and significantly lower weight until 12 months. Growth trajectories in the steroid and placebo arms differed significantly for length (P < .0001), weight (P = .009), and head circumference (P < .0001) with the largest impact noted for those with successful HPE. Growth trajectory for head circumference was significantly lower in patients treated with steroids irrespective of HPE status, but recovered during the second 6 months of life. CONCLUSIONS Steroid therapy following HPE in patients with biliary atresia is associated with impaired length, weight, and head circumference growth trajectories for at least 6 months post-HPE, especially impacting infants with successful bile drainage. TRIAL REGISTRATION ClinicalTrials.gov: NCT00294684.
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Affiliation(s)
- Estella M Alonso
- Division of Gastroenterology, Hepatology, and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Wen Ye
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | | | - Veena Venkat
- Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Cara L Mack
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Paula M Hertel
- Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Houston, TX
| | - Saul J Karpen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA
| | - Nanda Kerkar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA; Division of Pediatric Gastroenterology, The Mount Sinai School of Medicine, New York, NY
| | - Jean P Molleston
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, Rylie Hospital for Children, Indianapolis, IN
| | - Karen F Murray
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington and Seattle Children's, Seattle, WA
| | - Rene Romero
- Pediatrics, Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, San Francisco, CA
| | | | - Benjamin L Shneider
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Frederick J Suchy
- Children's Hospital Research Institute, Children's Hospital Colorado, Aurora, CO
| | | | - Kasper S Wang
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Averell H Sherker
- Liver Diseases Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Ronald J Sokol
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Jorge A Bezerra
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - John C Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
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12
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Shneider BL, Spino C, Kamath BM, Magee JC, Bass LM, Setchell KD, Miethke A, Molleston JP, Mack CL, Squires RH, Murray KF, Loomes KM, Rosenthal P, Karpen SJ, Leung DH, Guthery SL, Thomas D, Sherker AH, Sokol RJ. Placebo-Controlled Randomized Trial of an Intestinal Bile Salt Transport Inhibitor for Pruritus in Alagille Syndrome. Hepatol Commun 2018; 2:1184-1198. [PMID: 30288474 PMCID: PMC6167076 DOI: 10.1002/hep4.1244] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/13/2018] [Indexed: 01/06/2023] Open
Abstract
Medically refractory, severe, cholestasis-induced pruritus in Alagille syndrome may be improved by surgical interruption of the enterohepatic circulation. This multicenter trial (NCT02057692) tested the hypothesis that the intestinal bile acid transport inhibitor maralixibat would similarly reduce pruritus in Alagille syndrome. Thirty-seven children with Alagille syndrome were randomly assigned to double-blinded administration of placebo, 70, 140, or 280 µg/kg/day of maralixibat for 13 weeks. Pruritus was assessed by caregiver (itch-reported outcome instrument [ItchRO]) and clinician report (range, 0-4 [severe]). Liver chemistries and serum bile acids were measured. The primary outcome was the change from baseline to week 13 in ItchRO relative to placebo. In the a priori first analysis of the primary efficacy endpoint, the mean adjusted difference between participants receiving 140 or 280 µg/kg/day and placebo was -0.47 (95% confidence interval [CI], -1.14, 0.20; P = 0.16). Statistically significant decreases were observed with doses of 70 and 140 µg/kg/day (mean adjusted difference, -0.89; 95% CI, -1.70, -0.08; P = 0.032; and mean adjusted difference, -0.91; 95% CI, -1.62, -0.19; P = 0.014) but not 280 µg/kg/day (mean adjusted difference, -0.04; 95% CI, -0.94, 0.86; P = 0.44) or all doses combined (mean adjusted difference, -0.61; 95% CI, -1.24, 0.20; P = 0.055). A 1-point reduction in pruritus was more common in maralixibat-treated versus placebo-treated participants (caregiver ItchRO, 65% versus 25%; P = 0.06; clinician score, 76% versus 25%; P = 0.01). There were no significant changes in liver chemistries or bile acids relative to placebo. Adverse and serious adverse events were similar between maralixibat and placebo. Conclusion: Although the prespecified primary analyses of ItchRO were not all statistically significant, the data suggest that maralixibat is safe and may reduce pruritus in Alagille syndrome.
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Affiliation(s)
- Benjamin L. Shneider
- Section of Pediatric Gastroenterology, Hepatology, and NutritionBaylor College of MedicineHoustonTX
| | - Cathie Spino
- School of Public HealthUniversity of MichiganAnn ArborMI
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick ChildrenUniversity of TorontoTorontoCanada
| | | | - Lee M. Bass
- Pediatrics Division of Gastroenterology, Hepatology, and NutritionAnn and Robert H. Lurie Children’s Hospital of ChicagoChicagoIL
| | - Kenneth D. Setchell
- Department of Pediatrics‐PathologyCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Alexander Miethke
- Division of Pediatric Gastroenterology, Hepatology, and NutritionCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - Jean P. Molleston
- Division of Pediatric Gastroenterology, Hepatology, and NutritionIndiana University School of Medicine/Riley Hospital for ChildrenIndianapolisIN
| | - Cara L. Mack
- Section of Pediatric Gastroenterology, Hepatology, and NutritionChildren's Hospital ColoradoAuroraCO
| | | | - Karen F. Murray
- Division of Gastroenterology and HepatologyUniversity of Washington School of Medicine, Seattle Children’s HospitalSeattleWA
| | - Kathleen M. Loomes
- Pediatric Gastroenterology, Hepatology, and NutritionChildren’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of PediatricsUniversity of California San FranciscoSan FranciscoCA
| | - Saul J. Karpen
- Pediatric Gastroenterology, Hepatology, and NutritionEmory University School of Medicine/Children’s Healthcare of AtlantaAtlantaGA
| | - Daniel H. Leung
- Section of Pediatric Gastroenterology, Hepatology, and NutritionBaylor College of MedicineHoustonTX
| | - Stephen L. Guthery
- Pediatric Gastroenterology, Hepatology, and NutritionUniversity of UtahSalt Lake CityUT
| | - Danny Thomas
- Department of GastroenterologyChildren's Hospital Los AngelesLos AngelesCA
| | - Averell H. Sherker
- Liver Diseases Research Branch, National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of HealthBethesdaMD
| | - Ronald J. Sokol
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of PediatricsUniversity of Colorado School of MedicineAuroraCO
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13
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Butt Z, DiMartini AF, Liu Q, Simpson MA, Smith AR, Zee J, Gillespie BW, Holtzman S, Ladner D, Olthoff K, Fisher RA, Hafliger S, Freise CE, Mandell MS, Sherker AH, Dew MA. Fatigue, Pain, and Other Physical Symptoms of Living Liver Donors in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study. Liver Transpl 2018; 24:1221-1232. [PMID: 29698577 PMCID: PMC6153054 DOI: 10.1002/lt.25185] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/10/2018] [Indexed: 12/15/2022]
Abstract
Little is known about living liver donors' perceptions of their physical well-being following the procedure. We collected data on donor fatigue, pain, and other relevant physical outcomes as part of the prospective, multicenter Adult-to-Adult Living Donor Liver Transplantation Cohort Study consortium. A total of 271 (91%) of 297 eligible donors were interviewed at least once before donation and 3, 6, 12, and 24 months after donation using validated measures when available. Repeated measures regression models were used to identify potential predictors of worse physical outcomes. We found that donors reported more fatigue immediately after surgery that improved by 2 years after donation, but not to predonation levels. A similar pattern was seen across a number of other physical outcomes. Abdominal or back pain and interference from their pain were rated relatively low on average at all study points. However, 21% of donors did report clinically significant pain at some point during postdonation study follow-up. Across multiple outcomes, female donors, donors whose recipients died, donors with longer hospital stays after surgery, and those whose families discouraged donation were at risk for worse physical well-being outcomes. In conclusion, although not readily modifiable, we have identified risk factors that may help identify donors at risk for worse physical outcomes for targeted intervention. Liver Transplantation 00 000-000 2018 AASLD.
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Affiliation(s)
- Zeeshan Butt
- Departments of Medical Social Sciences, Surgery, & Psychiatry and Behavioral Sciences Northwestern University, Chicago IL
| | - Andrea F. DiMartini
- Departments of Psychiatry, Psychology, Epidemiology, Biostatistics, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh PA
| | - Qian Liu
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Mary Ann Simpson
- Department of Transplantation, Lahey Hospital and Medical Center, Burlington, MA
| | - Abigail R. Smith
- Arbor Research Collaborative for Health, Ann Arbor, MI,Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Susan Holtzman
- Department of Psychology, University of British Columbia, Kelowna, BC
| | - Daniela Ladner
- Departments of Medical Social Sciences, Surgery, & Psychiatry and Behavioral Sciences Northwestern University, Chicago IL
| | - Kim Olthoff
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Robert A. Fisher
- Division of Transplantation, The Transplant Institute Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
| | | | - Chris E. Freise
- Departments of Medicine and Surgery, University of California at San Francisco, San Francisco, CA
| | | | - Averell H. Sherker
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Mary Amanda Dew
- Departments of Psychiatry, Psychology, Epidemiology, Biostatistics, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh PA
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14
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Hayashi PH, Rockey D, Fontana RJ, Tillmann HL, Kaplowitz N, Barnhart H, Gu J, Chalasani NP, Reddy KR, Sherker AH, Hoofnagle JH. Death and liver transplantation within 2 years of onset of drug-induced liver injury. Hepatology 2017; 66:1275-1285. [PMID: 28543844 PMCID: PMC5605419 DOI: 10.1002/hep.29283] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/19/2017] [Accepted: 05/15/2017] [Indexed: 12/27/2022]
Abstract
UNLABELLED Drug-induced liver injury (DILI) is an important cause of death and indication for liver transplantation (fatality). The role of DILI in these fatalities is poorly characterized, particularly when fatalities occur >26 weeks after DILI onset. We analyzed patients in the US Drug-Induced Liver Injury Network prospective study having a fatal outcome within 2 years of onset. Each case was reviewed by eight network investigators and categorized as DILI having a primary, a contributory, or no role in the fatality. We subcategorized primary role cases as acute, chronic, acute-on-chronic, or acute cholestatic liver failure. For contributory and no role cases, we assigned a primary cause of death. Among 1,089 patients, 107 (9.8%) fatalities occurred within 2 years. DILI had a primary role in 68 (64%), a contributory role in 15 (14%), and no role in 22 (21%); 2 had insufficient data. Among primary role cases, 74% had acute, 13% chronic, 7% acute on chronic, and 6% acute cholestatic failure. For the 15 contributory role cases, common causes of death included sepsis, malignancy, and severe cutaneous reactions with multiorgan failure. For the 22 no role cases, malignancies accounted for most fatalities. Higher bilirubin, coagulopathy, leukocytosis, and thrombocytopenia were independently associated with DILI fatalities. New R ratio Hy's law had a higher positive predictive value for overall fatality (14% versus 10%) and a stronger independent association with DILI fatalities within 26 weeks compared to the original version of Hy's law (hazard ratio, 6.2, 95% confidence interval 3.4-11.1, versus 2.2, 95% confidence interval 1.3-3.7). CONCLUSIONS DILI leads directly or indirectly to fatality in 7.6% of cases; 40% of these had nonacute liver failure courses. New R ratio Hy's law better identifies risk for death compared to the original Hy's law. (Hepatology 2017;66:1275-1285).
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Affiliation(s)
- Paul H. Hayashi
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC
| | - Don Rockey
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC
| | | | | | - Neil Kaplowitz
- Division of Gastroenterology, University of Southern California, Los Angeles, CA
| | - Huiman Barnhart
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Jiezhan Gu
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Naga P. Chalasani
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN
| | - K. Rajender Reddy
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA
| | - Averell H. Sherker
- Liver Disease Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Jay H. Hoofnagle
- Liver Disease Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
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15
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Shneider BL, Moore J, Kerkar N, Magee JC, Ye W, Karpen SJ, Kamath BM, Molleston JP, Bezerra JA, Murray KF, Loomes KM, Whitington PF, Rosenthal P, Squires RH, Guthery SL, Arnon R, Schwarz KB, Turmelle YP, Sherker AH, Sokol RJ. Initial assessment of the infant with neonatal cholestasis-Is this biliary atresia? PLoS One 2017; 12:e0176275. [PMID: 28493866 PMCID: PMC5426590 DOI: 10.1371/journal.pone.0176275] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 04/07/2017] [Indexed: 01/29/2023] Open
Abstract
Introduction Optimizing outcome in biliary atresia (BA) requires timely diagnosis. Cholestasis is a presenting feature of BA, as well as other diagnoses (Non-BA). Identification of clinical features of neonatal cholestasis that would expedite decisions to pursue subsequent invasive testing to correctly diagnose or exclude BA would enhance outcomes. The analytical goal was to develop a predictive model for BA using data available at initial presentation. Methods Infants at presentation with neonatal cholestasis (direct/conjugated bilirubin >2 mg/dl [34.2 μM]) were enrolled prior to surgical exploration in a prospective observational multi-centered study (PROBE–NCT00061828). Clinical features (physical findings, laboratory results, gallbladder sonography) at enrollment were analyzed. Initially, 19 features were selected as candidate predictors. Two approaches were used to build models for diagnosis prediction: a hierarchical classification and regression decision tree (CART) and a logistic regression model using a stepwise selection strategy. Results In PROBE April 2004-February 2014, 401 infants met criteria for BA and 259 for Non-BA. Univariate analysis identified 13 features that were significantly different between BA and Non-BA. Using a CART predictive model of BA versus Non-BA (significant factors: gamma-glutamyl transpeptidase, acholic stools, weight), the receiver operating characteristic area under the curve (ROC AUC) was 0.83. Twelve percent of BA infants were misclassified as Non-BA; 17% of Non-BA infants were misclassified as BA. Stepwise logistic regression identified seven factors in a predictive model (ROC AUC 0.89). Using this model, a predicted probability of >0.8 (n = 357) yielded an 81% true positive rate for BA; <0.2 (n = 120) yielded an 11% false negative rate. Conclusion Despite the relatively good accuracy of our optimized prediction models, the high precision required for differentiating BA from Non-BA was not achieved. Accurate identification of BA in infants with neonatal cholestasis requires further evaluation, and BA should not be excluded based only on presenting clinical features.
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Affiliation(s)
- Benjamin L. Shneider
- Pediatric Gastroenterology, Hepatology, and Nutrition; Baylor College of Medicine; Houston, Texas, United States
- * E-mail:
| | - Jeff Moore
- Department of Biostatistics; University of Michigan; Ann Arbor, Michigan, United States
| | - Nanda Kerkar
- Children’s Hospital of Los Angeles; Los Angeles, California, United States
- Mount Sinai; New York, New York, United States
| | - John C. Magee
- University of Michigan Medical School; Ann Arbor, Michigan, United States
| | - Wen Ye
- Department of Biostatistics; University of Michigan; Ann Arbor, Michigan, United States
| | - Saul J. Karpen
- Pediatric Gastroenterology, Hepatology, and Nutrition; Emory University School of Medicine/Children’s Healthcare of Atlanta; Atlanta, Georgia, United States
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology, and Nutrition; Hospital for Sick Children and University of Toronto; Toronto, Ontario, Canada
| | - Jean P. Molleston
- Pediatric Gastroenterology, Hepatology, and Nutrition; Indiana University School of Medicine/Riley Hospital for Children; Indianapolis, Indiana, United States
| | - Jorge A. Bezerra
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition; Cincinnati Children’s Hospital Medical Center; Cincinnati, Ohio, United States
| | - Karen F. Murray
- Division of Gastroenterology and Hepatology; University of Washington Medical Center; Seattle Children’s; Seattle, Washington, United States
| | - Kathleen M. Loomes
- Pediatric Gastroenterology, Hepatology, and Nutrition; Children’s Hospital of Philadelphia; Philadelphia, Pennsylvania, United States
| | - Peter F. Whitington
- Pediatrics Division of Gastroenterology, Hepatology, and Nutrition; Ann and Robert H. Lurie Children’s Hospital of Chicago; Chicago, Illinois, United States
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition; Department of Pediatrics; University of California San Francisco; San Francisco, California, United States
| | - Robert H. Squires
- Children’s Hospital of Pittsburgh; Pittsburgh, Pennsylvania, United States
| | - Stephen L. Guthery
- Pediatric Gastroenterology, Hepatology, and Nutrition; University of Utah; Salt Lake City, Utah, United States
| | - Ronen Arnon
- Mount Sinai; New York, New York, United States
| | | | - Yumirle P. Turmelle
- Washington University School of Medicine; St. Louis, Missouri, United States
| | - Averell H. Sherker
- Liver Diseases Research Branch; National Institute of Diabetes and Digestive and Kidney Diseases; National Institutes of Health; Bethesda, Maryland, United States
| | - Ronald J. Sokol
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics; University of Colorado School of Medicine; Children’s Hospital Colorado; Aurora, Colorado, United States
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16
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Affiliation(s)
- Jay H Hoofnagle
- From National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Averell H Sherker
- From National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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17
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Butt Z, Dew MA, Liu Q, Simpson MA, Smith AR, Zee J, Gillespie BW, Abbey SE, Ladner DP, Weinrieb R, Fisher RA, Hafliger S, Terrault N, Burton J, Sherker AH, DiMartini A. Psychological Outcomes of Living Liver Donors From a Multicenter Prospective Study: Results From the Adult-to-Adult Living Donor Liver Transplantation Cohort Study2 (A2ALL-2). Am J Transplant 2017; 17:1267-1277. [PMID: 27865040 PMCID: PMC5612366 DOI: 10.1111/ajt.14134] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 10/21/2016] [Accepted: 11/08/2016] [Indexed: 01/25/2023]
Abstract
Although single-center and cross-sectional studies have suggested a modest impact of liver donation on donor psychological well-being, few studies have assessed these outcomes prospectively among a large cohort. We conducted one of the largest, prospective, multicenter studies of psychological outcomes in living liver donors within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study2 (A2ALL-2) consortium. In total, 271 (91%) of 297 eligible donors were interviewed at least once before donation and at 3, 6, 12, and 24 mo after donation using validated measures. We found that living liver donors reported low rates of major depressive (0-3%), alcohol abuse (2-5%), and anxiety syndromes (2-3%) at any given assessment in their first 2 years after donation. Between 4.7% and 9.6% of donors reported impaired mental well-being at various time points. We identified significant predictors for donors' perceptions of being better people and experiencing psychological growth following donation, including age, sex, relationship to recipient, ambivalence and motivation regarding donation, and feeling that donation would make life more worthwhile. Our results highlight the need for close psychosocial monitoring for those donors whose recipients died (n=27); some of those donors experienced guilt and concerns about responsibility. Careful screening and targeted, data-driven follow-up hold promise for optimizing psychological outcomes following this procedure for potentially vulnerable donors.
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Affiliation(s)
- Z Butt
- Departments of Medical Social Sciences, Surgery, & Psychiatry and Behavioral Sciences Northwestern University, Chicago IL
| | - MA Dew
- Departments of Psychiatry, Surgery, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh PA
| | - Q Liu
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | - MA Simpson
- Department of Transplantation, Lahey Hospital and Medical Center, Burlington, MA
| | - AR Smith
- Arbor Research Collaborative for Health, Ann Arbor, MI,Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - J Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | - BW Gillespie
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - SE Abbey
- Department of Psychiatry and Transplantation, University Health Network, University of Toronto, Toronto, Ontario, CA
| | - DP Ladner
- Departments of Medical Social Sciences, Surgery, & Psychiatry and Behavioral Sciences Northwestern University, Chicago IL
| | - R Weinrieb
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - RA Fisher
- Professor of Surgery, Harvard Medical School Chief, Division of Transplantation, The Transplant Institute Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
| | - S Hafliger
- Department of Psychiatry, Columbia University, New York, NY
| | - N Terrault
- Departments of Medicine and Surgery, University of California at San Francisco, San Francisco, CA
| | - J Burton
- Department of Medicine, University of Colorado, Denver, Aurora, CO
| | - AH Sherker
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - A DiMartini
- Departments of Psychiatry, Surgery, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh PA
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18
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DiMartini A, Dew MA, Liu Q, Simpson MA, Ladner DP, Smith AR, Zee J, Abbey S, Gillespie BW, Weinrieb R, Mandell MS, Fisher RA, Emond JC, Freise CE, Sherker AH, Butt Z. Social and Financial Outcomes of Living Liver Donation: A Prospective Investigation Within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study 2 (A2ALL-2). Am J Transplant 2017; 17:1081-1096. [PMID: 27647626 PMCID: PMC5359081 DOI: 10.1111/ajt.14055] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 08/04/2016] [Accepted: 09/07/2016] [Indexed: 01/25/2023]
Abstract
Because results from single-center (mostly kidney) donor studies demonstrate interpersonal relationship and financial strains for some donors, we conducted a liver donor study involving nine centers within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study 2 (A2ALL-2) consortium. Among other initiatives, A2ALL-2 examined the nature of these outcomes following donation. Using validated measures, donors were prospectively surveyed before donation and at 3, 6, 12, and 24 mo after donation. Repeated-measures regression models were used to examine social relationship and financial outcomes over time and to identify relevant predictors. Of 297 eligible donors, 271 (91%) consented and were interviewed at least once. Relationship changes were positive overall across postdonation time points, with nearly one-third reporting improved donor family and spousal or partner relationships and >50% reporting improved recipient relationships. The majority of donors, however, reported cumulative out-of-pocket medical and nonmedical expenses, which were judged burdensome by 44% of donors. Lower income predicted burdensome donation costs. Those who anticipated financial concerns and who held nonprofessional positions before donation were more likely to experience adverse financial outcomes. These data support the need for initiatives to reduce financial burden.
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Affiliation(s)
- A DiMartini
- Department of Psychiatry, University of Pittsburgh, Pittsburgh PA, USA,Department of Surgery, University of Pittsburgh, Pittsburgh PA, USA
| | - MA Dew
- Department of Psychiatry, University of Pittsburgh, Pittsburgh PA, USA,Department of Psychology, University of Pittsburgh, Pittsburgh PA, USA,Department of Epidemiology, University of Pittsburgh, Pittsburgh PA, USA,Department of Biostatistics, University of Pittsburgh, Pittsburgh PA, USA
| | - Q Liu
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - MA Simpson
- Lahey Hospital and Medical Center Clinical Research and Education, Burlington, MA, USA,Department of Transplantation, Burlington, MA, USA
| | - DP Ladner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Chicago, IL, USA,Comprehensive Transplant Center, Northwestern University, Chicago, IL, USA
| | - AR Smith
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA,Departments of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - J Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - S Abbey
- Department of Psychiatry, University of Toronto and University Health Network, Toronto ON, CA
| | - BW Gillespie
- Departments of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - R Weinrieb
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - MS Mandell
- Department of Anesthesiology, University of Colorado, Denver CO, USA
| | - RA Fisher
- Department of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA (current affiliation, Beth Israel Deaconess Department of Surgery, Harvard University)
| | - JC Emond
- Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - CE Freise
- Department of Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - AH Sherker
- Liver Diseases Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Z Butt
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Chicago, IL, USA,Comprehensive Transplant Center, Northwestern University, Chicago, IL, USA,Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago IL, USA,Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago IL, USA
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19
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Abstract
The increase in the use of herbal and dietary supplements (HDSs) over the last decades has been accompanied by an increase in the reports of HDS-associated hepatotoxicity. The spectrum of HDS-induced liver injury is diverse and the outcome may vary from transient liver test increases to fulminant hepatic failure resulting in death or requiring liver transplant. There are no validated standardized tools to establish the diagnosis, but some HDS products have a typical clinical signature that may help to identify HDS-induced liver injury.
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Affiliation(s)
- Ynto S. de Boer
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
,Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Averell H. Sherker
- Liver Diseases Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
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20
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Reuben A, Tillman H, Fontana RJ, Davern T, McGuire B, Stravitz RT, Durkalski V, Larson AM, Liou I, Fix O, Schilsky M, McCashland T, Hay JE, Murray N, Shaikh OS, Ganger D, Zaman A, Han SB, Chung RT, Smith A, Brown R, Crippin J, Harrison ME, Koch D, Munoz S, Reddy KR, Rossaro L, Satyanarayana R, Hassanein T, Hanje AJ, Olson J, Subramanian R, Karvellas C, Hameed B, Sherker AH, Robuck P, Lee WM. Outcomes in Adults With Acute Liver Failure Between 1998 and 2013: An Observational Cohort Study. Ann Intern Med 2016; 164:724-32. [PMID: 27043883 PMCID: PMC5526039 DOI: 10.7326/m15-2211] [Citation(s) in RCA: 238] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute liver failure (ALF) is a rare syndrome of severe, rapid-onset hepatic dysfunction-without prior advanced liver disease-that is associated with high morbidity and mortality. Intensive care and liver transplantation provide support and rescue, respectively. OBJECTIVE To determine whether changes in causes, disease severity, treatment, or 21-day outcomes have occurred in recent years among adult patients with ALF referred to U.S. tertiary care centers. DESIGN Prospective observational cohort study. (ClinicalTrials .gov: NCT00518440). SETTING 31 liver disease and transplant centers in the United States. PATIENTS Consecutively enrolled patients-without prior advanced liver disease-with ALF (n = 2070). MEASUREMENTS Clinical features, treatment, and 21-day outcomes were compared over time annually for trends and were also stratified into two 8-year periods (1998 to 2005 and 2006 to 2013). RESULTS Overall clinical characteristics, disease severity, and distribution of causes remained similar throughout the study period. The 21-day survival rates increased between the two 8-year periods (overall, 67.1% vs. 75.3%; transplant-free survival [TFS], 45.1% vs. 56.2%; posttransplantation survival, 88.3% vs. 96.3% [P < 0.010 for each]). Reductions in red blood cell infusions (44.3% vs. 27.6%), plasma infusions (65.2% vs. 47.1%), mechanical ventilation (65.7% vs. 56.1%), and vasopressors (34.9% vs. 27.8%) were observed, as well as increased use of N-acetylcysteine (48.9% vs. 69.3% overall; 15.8% vs. 49.4% [P < 0.001] in patients with ALF not due to acetaminophen toxicity). When examined longitudinally, overall survival and TFS increased throughout the 16-year period. LIMITATIONS The duration of enrollment, the number of patients enrolled, and possibly the approaches to care varied among participating sites. The results may not be generalizable beyond such specialized centers. CONCLUSION Although characteristics and severity of ALF changed little over 16 years, overall survival and TFS improved significantly. The effects of specific changes in intensive care practice on survival warrant further study. PRIMARY FUNDING SOURCE National Institutes of Health.
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21
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Shneider BL, Magee JC, Karpen SJ, Rand EB, Narkewicz MR, Bass LM, Schwarz K, Whitington PF, Bezerra JA, Kerkar N, Haber B, Rosenthal P, Turmelle YP, Molleston JP, Murray KF, Ng VL, Wang KS, Romero R, Squires RH, Arnon R, Sherker AH, Moore J, Ye W, Sokol RJ. Total Serum Bilirubin within 3 Months of Hepatoportoenterostomy Predicts Short-Term Outcomes in Biliary Atresia. J Pediatr 2016; 170:211-7.e1-2. [PMID: 26725209 PMCID: PMC4826612 DOI: 10.1016/j.jpeds.2015.11.058] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 11/04/2015] [Accepted: 11/23/2015] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To prospectively assess the value of serum total bilirubin (TB) within 3 months of hepatoportoenterostomy (HPE) in infants with biliary atresia as a biomarker predictive of clinical sequelae of liver disease in the first 2 years of life. STUDY DESIGN Infants with biliary atresia undergoing HPE between June 2004 and January 2011 were enrolled in a prospective, multicenter study. Complications were monitored until 2 years of age or the earliest of liver transplantation (LT), death, or study withdrawal. TB below 2 mg/dL (34.2 μM) at any time in the first 3 months (TB <2.0, all others TB ≥ 2) after HPE was examined as a biomarker, using Kaplan-Meier survival and logistic regression. RESULTS Fifty percent (68/137) of infants had TB < 2.0 in the first 3 months after HPE. Transplant-free survival at 2 years was significantly higher in the TB < 2.0 group vs TB ≥ 2 (86% vs 20%, P < .0001). Infants with TB ≥ 2 had diminished weight gain (P < .0001), greater probability of developing ascites (OR 6.4, 95% CI 2.9-14.1, P < .0001), hypoalbuminemia (OR 7.6, 95% CI 3.2-17.7, P < .0001), coagulopathy (OR 10.8, 95% CI 3.1-38.2, P = .0002), LT (OR 12.4, 95% CI 5.3-28.7, P < .0001), or LT or death (OR 16.8, 95% CI 7.2-39.2, P < .0001). CONCLUSIONS Infants whose TB does not fall below 2.0 mg/dL within 3 months of HPE were at high risk for early disease progression, suggesting they should be considered for LT in a timely fashion. Interventions increasing the likelihood of achieving TB <2.0 mg/dL within 3 months of HPE may enhance early outcomes. TRIAL REGISTRATION ClinicalTrials.gov: NCT00061828 and NCT00294684.
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Affiliation(s)
- Benjamin L. Shneider
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - John C. Magee
- University of Michigan Medical School, Ann Arbor, MI
| | - Saul J. Karpen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine/Children’s Healthcare of Atlanta
| | - Elizabeth B. Rand
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Michael R. Narkewicz
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO
| | - Lee M. Bass
- Pediatrics Division of Gastroenterology, Hepatology, and Nutrition, Ann and Robert H Lurie Children’s Hospital of Chicago, Chicago, IL
| | | | - Peter F. Whitington
- Pediatrics Division of Gastroenterology, Hepatology, and Nutrition, Ann and Robert H Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Jorge A. Bezerra
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Nanda Kerkar
- Division of Gastroenterology, Hepatology and Nutrition, Childrens’ Hospital of Los Angeles, University of Southern California, Los Angeles, CA
| | - Barbara Haber
- Merck Sharp and Dohme Corp, Merck Research Laboratories, North Wales, PA
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, UCSF Benioff Children’s Hospital, San Francisco, CA
| | | | - Jean P. Molleston
- Department of Pediatrics, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, IN
| | - Karen F. Murray
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington and Seattle Children’s. Seattle, WA
| | - Vicky L. Ng
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kasper S. Wang
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, CA
| | - Rene Romero
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University, Atlanta, GA
| | | | - Ronen Arnon
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Mount Sinai Medical Center, New York, NY
| | - Averell H. Sherker
- Liver Diseases Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Jeffrey Moore
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Wen Ye
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Ronald J. Sokol
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora CO
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22
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Leung DH, Ye W, Molleston JP, Weymann A, Ling S, Paranjape SM, Romero R, Schwarzenberg SJ, Palermo J, Alonso EM, Murray KF, Marshall BC, Sherker AH, Siegel MJ, Krishnamurthy R, Harned R, Karmazyn B, Magee JC, Narkewicz MR. Baseline Ultrasound and Clinical Correlates in Children with Cystic Fibrosis. J Pediatr 2015; 167:862-868.e2. [PMID: 26254836 PMCID: PMC4586395 DOI: 10.1016/j.jpeds.2015.06.062] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 05/18/2015] [Accepted: 06/26/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate the relationship between abdominal ultrasound findings and demographic, historical, and clinical features in children with cystic fibrosis (CF). STUDY DESIGN Children age 3-12 years with CF without known cirrhosis, were enrolled in a prospective, multicenter study of ultrasound to predict hepatic fibrosis. Consensus ultrasound patterns were assigned by 3 radiologists as normal, heterogeneous, homogeneous, or cirrhosis. Data were derived from direct collection and US or Toronto CF registries. χ(2) or ANOVA were used to compare variables among ultrasound groups and between normal and abnormal. Logistic regression was used to study risk factors for having abnormal ultrasound. RESULTS Findings in 719 subjects were normal (n = 590, 82.1%), heterogeneous (64, 8.9%), homogeneous (41, 5.7%), and cirrhosis (24, 3.3%). Cirrhosis (P = .0004), homogeneous (P < .0001), and heterogeneous (P = .03) were older than normal. More males were heterogeneous (P = .001). More heterogeneous (15.0%, P = .009) and cirrhosis (25.0%, P = .005) had CF-related diabetes or impaired glucose tolerance vs normal (5.4%). Early infection with Pseudomonas aeruginosa (<2 years old) was associated with a lower risk (OR 0.42, P = .0007) of abnormal. Ursodeoxycholic acid use (OR 3.69, P < .0001) and CF-related diabetes (OR 2.21, P = .019) were associated with increased risk of abnormal. CONCLUSIONS Unsuspected cirrhosis is seen in 3.3% of young patients with CF, heterogeneous in 8.9%. Abnormal ultrasound is associated with CF-related diabetes, and early P aeruginosa is associated with normal ultrasound. Prospective assessment of these risk factors may identify potential interventional targets. TRIAL REGISTRATION ClinicalTrials.gov: NCT01144507.
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Affiliation(s)
- Daniel H. Leung
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine/Texas Children's Hospital, Houston TX
| | - Wen Ye
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Jean P. Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine Riley Hospital for Children, Indianapolis IN
| | - Alexander Weymann
- Division of Gastroenterology, Hepatology, and Nutrition, Washington University School of Medicine, St. Louis MO
| | - Simon Ling
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, and Department of Paediatrics, University of Toronto, Toronto Ontario, Canada
| | - Shruti M. Paranjape
- Division of Pediatric Pulmonology, Johns Hopkins University School of Medicine, Baltimore MD
| | - Rene Romero
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Atlanta GA
| | - Sara Jane Schwarzenberg
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Minnesota Masonic Children's Hospital, Minneapolis MN
| | - Joseph Palermo
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati OH
| | - Estella M. Alonso
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert Lurie Children's Hospital, Chicago IL
| | - Karen F. Murray
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital and University of Washington, Seattle WA
| | | | - Averell H. Sherker
- Liver Diseases Research Branch, Division of Digestive Diseases and Nutrition, NIDDK, Bethesda MD
| | - Marilyn J. Siegel
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis MO
| | - Rajesh Krishnamurthy
- EB Singleton Department of Diagnostic Imaging, Texas Children's Hospital, Houston TX
| | - Roger Harned
- Department of Radiology, University of Colorado SOM and Children's Hospital Colorado, Aurora CO
| | - Boaz Karmazyn
- Pediatric Radiology, Riley Hospital for Children, Indianapolis IN
| | - John C. Magee
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michael R Narkewicz
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado SOM and Children's Hospital Colorado, Aurora, CO.
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23
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Kamath BM, Chen Z, Romero R, Fredericks EM, Alonso EM, Arnon R, Heubi J, Hertel PM, Karpen SJ, Loomes KM, Murray KF, Rosenthal P, Schwarz KB, Subbarao G, Teckman JH, Turmelle YP, Wang KS, Sherker AH, Sokol RJ, Magee JC. Quality of Life and Its Determinants in a Multicenter Cohort of Children with Alagille Syndrome. J Pediatr 2015; 167:390-6.e3. [PMID: 26059338 PMCID: PMC4516587 DOI: 10.1016/j.jpeds.2015.04.077] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/11/2015] [Accepted: 04/30/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To assess health-related quality of life (HRQOL) in children with Alagille syndrome (ALGS) in comparison with healthy and other liver disease cohorts, and to identify determinants of HRQOL in patients with ALGS. STUDY DESIGN Within the Childhood Liver Disease Research Network prospective study of cholestasis, Pediatric Quality of Life Inventory (PedsQL) questionnaires were administered to 70 children with ALGS, 95 children with alpha-1-antitrypsin deficiency (A1ATD), and 49 children with other causes of chronic intrahepatic cholestasis (IHC) aged 5-18 years. Parent proxy PedsQL scores were recorded for children aged 2-18 years (98 ALGS, 123 A1ATD, and 68 IHC). RESULTS Mean ages and total bilirubin (mg/dL) were ALGS 9.4 years; 4.4, A1ATD 9.5 years; 0.7, and IHC 10.3 years; 2.9. ALGS child PedsQL scores were lower than in healthy children and children with A1ATD (mean 73 vs 83; P = .001). Children with ALGS and IHC were similar, except in physical scores (73 vs 79; P = .05). Parents of children with ALGS perceived their children to have worse HRQOL than A1ATD (P ≤ .001) and marginally lower compared with IHC. Univariate analysis revealed ALGS child-reported scores were positively associated with better growth and inversely with total bilirubin. Growth failure, elevated international normalized ratio, and an intracardiac defect were predictive of poor parental scores (P ≤ .05). In multivariate analysis, only weight z-score remained significant for child- and parent-reported scores. CONCLUSIONS HRQOL is impaired in children with ALGS compared with healthy and children with A1ATD, similar to children with IHC and is associated with growth failure, which is a potentially treatable cause of impaired HRQOL.
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Affiliation(s)
- Binita M Kamath
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada.
| | - Zhen Chen
- University of Michigan, Ann Arbor, MI
| | - Rene Romero
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | | | - Estella M Alonso
- Ann and Robert H. Lurie Children's Hospital and Northwestern University, Chicago, IL
| | - Ronen Arnon
- Mount Sinai Medical Center, New York City, NY
| | - James Heubi
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Paula M Hertel
- Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Saul J Karpen
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Kathleen M Loomes
- The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Karen F Murray
- Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, WA
| | | | | | - Girish Subbarao
- Riley Hospital for Children, Indiana University, Indianapolis, IN
| | | | | | | | - Averell H Sherker
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Ronald J Sokol
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
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24
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Navarro VJ, Barnhart H, Bonkovsky HL, Davern T, Fontana RJ, Grant L, Reddy KR, Seeff LB, Serrano J, Sherker AH, Stolz A, Talwalkar J, Vega M, Vuppalanchi R. Liver injury from herbals and dietary supplements in the U.S. Drug-Induced Liver Injury Network. Hepatology 2014; 60:1399-408. [PMID: 25043597 PMCID: PMC4293199 DOI: 10.1002/hep.27317] [Citation(s) in RCA: 253] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 07/10/2014] [Indexed: 02/06/2023]
Abstract
UNLABELLED The Drug-Induced Liver Injury Network (DILIN) studies hepatotoxicity caused by conventional medications as well as herbals and dietary supplements (HDS). To characterize hepatotoxicity and its outcomes from HDS versus medications, patients with hepatotoxicity attributed to medications or HDS were enrolled prospectively between 2004 and 2013. The study took place among eight U.S. referral centers that are part of the DILIN. Consecutive patients with liver injury referred to a DILIN center were eligible. The final sample comprised 130 (15.5%) of all subjects enrolled (839) who were judged to have experienced liver injury caused by HDS. Hepatotoxicity caused by HDS was evaluated by expert opinion. Demographic and clinical characteristics and outcome assessments, including death and liver transplantation (LT), were ascertained. Cases were stratified and compared according to the type of agent implicated in liver injury; 45 had injury caused by bodybuilding HDS, 85 by nonbodybuilding HDS, and 709 by medications. Liver injury caused by HDS increased from 7% to 20% (P < 0.001) during the study period. Bodybuilding HDS caused prolonged jaundice (median, 91 days) in young men, but did not result in any fatalities or LT. The remaining HDS cases presented as hepatocellular injury, predominantly in middle-aged women, and, more frequently, led to death or transplantation, compared to injury from medications (13% vs. 3%; P < 0.05). CONCLUSIONS The proportion of liver injury cases attributed to HDS in DILIN has increased significantly. Liver injury from nonbodybuilding HDS is more severe than from bodybuilding HDS or medications, as evidenced by differences in unfavorable outcomes (death and transplantation). (Hepatology 2014;60:1399-1408).
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jose Serrano
- National Institute of Diabetes and Digestive and Kidney Diseases, Los Angeles, CA
| | - Averell H. Sherker
- National Institute of Diabetes and Digestive and Kidney Diseases, Los Angeles, CA
| | - Andrew Stolz
- University of Southern California, Los Angeles, CA
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25
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Ng VL, Haber BH, Magee JC, Miethke A, Murray KF, Michail S, Karpen SJ, Kerkar N, Molleston JP, Romero R, Rosenthal P, Schwarz KB, Shneider BL, Turmelle YP, Alonso EM, Sherker AH, Sokol RJ. Medical status of 219 children with biliary atresia surviving long-term with their native livers: results from a North American multicenter consortium. J Pediatr 2014; 165:539-546.e2. [PMID: 25015575 PMCID: PMC4144331 DOI: 10.1016/j.jpeds.2014.05.038] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/21/2014] [Accepted: 05/21/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To examine the medical status of children with biliary atresia (BA) with their native livers after hepato- portoenterostomy (HPE) surgery. STUDY DESIGN The Childhood Liver Disease Research and Education Network database was utilized to examine subjects with BA living with their native livers 5 or more years after HPE and to describe the prevalence of subjects with BA with an "ideal" outcome, defined as no clinical evidence of chronic liver disease, normal liver biochemical indices (aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transpeptidase, platelet count, total bilirubin, international normalized ratio, and albumin), and normal health-related quality of life 5 or more years after HPE. RESULTS Children with BA (n = 219; 43% male) with median age 9.7 years were studied. Median age at HPE was 56 (range 7-125) days. Median age- and sex-adjusted height and weight z-scores at 5-year follow-up were 0.487 (IQR -0.27 to 1.02) and 0.00 (IQR -0.74 to 0.70), respectively. During the 12 preceding months, cholangitis and bone fractures occurred in 17% and 5.5%, respectively. Health-related quality of life was reported normal by 53% of patients. However, only 1.8% met the study definition of "ideal" outcome. Individual tests of liver synthetic function (total bilirubin, albumin, and international normalized ratio) were normal in 75%, 85%, and 73% of the study cohort. CONCLUSION Cholangitis and fractures in long-term survivors underscore the importance of ongoing medical surveillance. Over 98% of this North American cohort of subjects with BA living with native livers 5 or more years after HPE have clinical or biochemical evidence of chronic liver disease.
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Affiliation(s)
- Vicky Lee Ng
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Barbara H Haber
- Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - John C Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Alexander Miethke
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Karen F Murray
- Hepatobiliary Program, Seattle Children's Hospital and University of Washington, Seattle, WA
| | - Sonia Michail
- Department of Gastroenterology and Nutrition, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA
| | - Saul J Karpen
- Texas Children's Hospital, Houston, TX; Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Nanda Kerkar
- Department of Gastroenterology and Nutrition, Children's Hospital Los Angeles, Keck School of Medicine University of Southern California, Los Angeles, CA; Division of Pediatric Hepatology, Mount Sinai School of Medicine, New York, NY
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology, and Nutrition, Riley Hospital for Children, Indiana University, Indianapolis, IN
| | - Rene Romero
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Philip Rosenthal
- Pediatrics Gastroenterology, Hepatology, and Nutrition, University of California San Francisco Benioff Children's Hospital, University of California, San Francisco, CA
| | - Kathleen B Schwarz
- Division of Pediatric Gastroenterology and Nutrition, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Benjamin L Shneider
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Yumirle P Turmelle
- Division of Gastroenterology and Nutrition, Washington University, St. Louis, MO
| | - Estella M Alonso
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann and Robert H. Lurie Children's Hospital and Northwestern University, Chicago, IL
| | | | - Ronald J Sokol
- Department of Gastroenterology, Hepatology, and Nutrition, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
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26
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Bezerra JA, Spino C, Magee JC, Shneider BL, Rosenthal P, Wang KS, Erlichman J, Haber B, Hertel PM, Karpen SJ, Kerkar N, Loomes KM, Molleston JP, Murray KF, Romero R, Schwarz KB, Shepherd R, Suchy FJ, Turmelle YP, Whitington PF, Moore J, Sherker AH, Robuck PR, Sokol RJ. Use of corticosteroids after hepatoportoenterostomy for bile drainage in infants with biliary atresia: the START randomized clinical trial. JAMA 2014; 311:1750-9. [PMID: 24794368 PMCID: PMC4303045 DOI: 10.1001/jama.2014.2623] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Biliary atresia is the most common cause of end-stage liver disease in children. Controversy exists as to whether use of steroids after hepatoportoenterostomy improves clinical outcome. OBJECTIVE To determine whether the addition of high-dose corticosteroids after hepatoportoenterostomy is superior to surgery alone in improving biliary drainage and survival with the native liver. DESIGN, SETTING, AND PATIENTS The multicenter, double-blind Steroids in Biliary Atresia Randomized Trial (START) was conducted in 140 infants (mean age, 2.3 months) between September 2005 and February 2011 in the United States; follow-up ended in January 2013. INTERVENTIONS Participants were randomized to receive intravenous methylprednisolone (4 mg/kg/d for 2 weeks) and oral prednisolone (2 mg/kg/d for 2 weeks) followed by a tapering protocol for 9 weeks (n = 70) or placebo (n = 70) initiated within 72 hours of hepatoportoenterostomy. MAIN OUTCOMES AND MEASURES The primary end point (powered to detect a 25% absolute treatment difference) was the percentage of participants with a serum total bilirubin level of less than 1.5 mg/dL with his/her native liver at 6 months posthepatoportoenterostomy. Secondary outcomes included survival with native liver at 24 months of age and serious adverse events. RESULTS The proportion of participants with improved bile drainage was not statistically significantly improved by steroids at 6 months posthepatoportoenterostomy (58.6% [41/70] of steroids group vs 48.6% [34/70] of placebo group; adjusted relative risk, 1.14 [95% CI, 0.83 to 1.57]; P = .43). The adjusted absolute risk difference was 8.7% (95% CI, -10.4% to 27.7%). Transplant-free survival was 58.7% in the steroids group vs 59.4% in the placebo group (adjusted hazard ratio, 1.0 [95% CI, 0.6 to 1.8]; P = .99) at 24 months of age. The percentage of participants with serious adverse events was 81.4% [57/70] of the steroids group and 80.0% [56/70] of the placebo group (P > .99); however, participants receiving steroids had an earlier time of onset of their first serious adverse event by 30 days posthepatoportoenterostomy (37.2% [95% CI, 26.9% to 50.0%] of steroids group vs 19.0% [95% CI, 11.5% to 30.4%] of placebo group; P = .008). CONCLUSIONS AND RELEVANCE Among infants with biliary atresia who have undergone hepatoportoenterostomy, high-dose steroid therapy following surgery did not result in statistically significant treatment differences in bile drainage at 6 months, although a small clinical benefit could not be excluded. Steroid treatment was associated with earlier onset of serious adverse events in children with biliary atresia. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00294684.
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Affiliation(s)
- Jorge A Bezerra
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | | | - Kasper S Wang
- Children's Hospital Los Angeles and University of Southern California, Los Angeles
| | - Jessi Erlichman
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Barbara Haber
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania17Dr Haber is now with Merck Research Laboratories, Upper Gwynedd, Pennsylvania
| | - Paula M Hertel
- Baylor College of Medicine and Texas Children's Hospital, Houston
| | - Saul J Karpen
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Nanda Kerkar
- Mount Sinai School of Medicine, New York, New York18Dr Kerkar is now with Children's Hospital Los Angeles and University of Southern California, Los Angeles
| | | | - Jean P Molleston
- Indiana University School of Medicine and Riley Hospital for Children, Indianapolis
| | | | - Rene Romero
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Ross Shepherd
- Baylor College of Medicine and Texas Children's Hospital, Houston
| | - Frederick J Suchy
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora
| | | | | | | | - Averell H Sherker
- National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Patricia R Robuck
- National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Ronald J Sokol
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora
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Affiliation(s)
- Jay H Hoofnagle
- From the Liver Diseases Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
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Werner JM, Heller T, Gordon AM, Sheets A, Sherker AH, Kessler E, Bean KS, Stevens M, Schmitt J, Rehermann B. Innate immune responses in hepatitis C virus-exposed healthcare workers who do not develop acute infection. Hepatology 2013; 58:1621-31. [PMID: 23463364 PMCID: PMC3688637 DOI: 10.1002/hep.26353] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 02/16/2013] [Indexed: 12/11/2022]
Abstract
UNLABELLED Hepatitis C virus (HCV) infection typically results in chronic disease with HCV outpacing antiviral immune responses. Here we asked whether innate immune responses are induced in healthcare workers who are exposed to small amounts of HCV, but do not develop systemic infection and acute liver disease. Twelve healthcare workers with accidental percutaneous exposure to HCV-infected blood were prospectively studied for up to 6 months for phenotype and function of natural killer T (NKT) and NK cells, kinetics of serum chemokines, and vigor and specificity of HCV-specific T-cell responses. Eleven healthcare workers tested negative for HCV RNA and HCV antibodies. All but one of these aviremic cases displayed NKT cell activation, increased serum chemokines levels, and NK cell responses with increased CD122, NKp44, NKp46, and NKG2A expression, cytotoxicity (as determined by TRAIL and CD107a expression), and interferon-gamma (IFN-γ) production. This multifunctional NK cell response appeared a month earlier than in the one healthcare worker who developed high-level viremia, and it differed from the impaired IFN-γ production, which is typical for NK cells in chronic HCV infection. The magnitude of NKT cell activation and NK cell cytotoxicity correlated with the magnitude of the subsequent HCV-specific T-cell response. T-cell responses targeted nonstructural HCV sequences that require translation of viral RNA, which suggests that transient or locally contained HCV replication occurred without detectable systemic viremia. CONCLUSION Exposure to small amounts of HCV induces innate immune responses, which correlate with the subsequent HCV-specific T-cell response and may contribute to antiviral immunity.
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Affiliation(s)
- Jens Martin Werner
- Liver Diseases Branch, NIDDK, National Institutes of Health, DHHS, 10 Center Drive, Bethesda, MD 20892-1800, USA
| | - Theo Heller
- Liver Diseases Branch, NIDDK, National Institutes of Health, DHHS, 10 Center Drive, Bethesda, MD 20892-1800, USA
| | - Ann Marie Gordon
- Occupational Health, Medstar Washington Hospital Center, 110 Irving Street, NW, Washington, DC 20010, USA
| | - Arlene Sheets
- Occupational Health, Medstar Washington Hospital Center, 110 Irving Street, NW, Washington, DC 20010, USA
| | - Averell H. Sherker
- Center for Liver Diseases, Washington Hospital Center, 110 Irving Street, NW, Washington, DC 20010, USA
| | - Ellen Kessler
- Employee Occupational Health, Inova Fairfax Hospital, 3300 Gallows Road Falls Church, VA 22042, USA
| | - Kathleen S. Bean
- Employee Occupational Health, Inova Fairfax Hospital, 3300 Gallows Road Falls Church, VA 22042, USA
| | - M'Lou Stevens
- Occupational Medical Service, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892-1584, USA
| | - James Schmitt
- Occupational Medical Service, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892-1584, USA
| | - Barbara Rehermann
- Liver Diseases Branch, NIDDK, National Institutes of Health, DHHS, 10 Center Drive, Bethesda, MD 20892-1800, USA
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29
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Heller T, Werner JM, Rahman F, Mizukoshi E, Sobao Y, Gordon AM, Sheets A, Sherker AH, Kessler E, Bean KS, Herrine SK, Stevens M, Schmitt J, Rehermann B. Occupational exposure to hepatitis C virus: early T-cell responses in the absence of seroconversion in a longitudinal cohort study. J Infect Dis 2013; 208:1020-5. [PMID: 23801608 DOI: 10.1093/infdis/jit270] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND T-cell responses have been described in seronegative patients who test negative for hepatitis C virus (HCV) RNA despite frequent HCV exposure. However, the cross-sectional design of those studies did not clarify whether T cells were indeed induced by low-level HCV exposure without seroconversion or whether they resulted from regular acute infection with subsequent antibody loss. METHODS Over a 10-year period, our longitudinal study recruited 72 healthcare workers with documented HCV exposure. We studied viremia and antibody and T-cell responses longitudinally for 6 months. RESULTS All healthcare workers remained negative for HCV RNA and antibodies. However, 48% developed proliferative T-cell response and 42% developed responses in interferon-gamma enzyme-linked immunosorbent spot assays, with 29 healthy HCV-unexposed controls used to define assay cutoffs. The response prevalence was associated with the transmission risk score. T-cell responses peaked at week 4 and returned to baseline by week 12 after exposure. They predominantly targeted nonstructural HCV proteins, which are not part of the HCV particle and thus must have been synthesized in infected cells. CONCLUSIONS Subclinical transmission of HCV occurs frequently, resulting in infection and synthesis of nonstructural proteins despite undetectable systemic viremia. T-cell responses are more sensitive indicators of this low-level HCV exposure than antibodies.
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Affiliation(s)
- Theo Heller
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland, USA
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30
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Sherker AH. Review: interferon and nucleoside/tide analogues reduce risk of hepato-cellular cancer in chronic hepatitis B. Evid Based Med 2009; 14:86. [PMID: 19483035 DOI: 10.1136/ebm.14.3.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Averell H Sherker
- Washington Hospital Center and Georgetown University Washington, DC, USA
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31
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Affiliation(s)
- Averell H Sherker
- Washington Hospital Center and Georgetown University, Washington, DC, USA
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Abstract
This article considers the extrahepatic manifestations associated with HBV and HCV infection, the strength of the evidence for the association, potential pathological mechanisms, and evidence based therapeutic recommendations. As many of these extra hepatic conditions are uncommon, published reports have been largely uncontrolled or anecdotal.
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Affiliation(s)
- Jae D Kim
- Section of Gastroenterology and Hepatology, Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA
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Al-Mukhaizeem KA, Rosenberg A, Sherker AH. Nodular regenerative hyperplasia of the liver: an under-recognized cause of portal hypertension in hematological disorders. Am J Hematol 2004; 75:225-30. [PMID: 15054815 DOI: 10.1002/ajh.20024] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Portal hypertension has been described in a wide variety of hematological disorders, especially myeloproliferative and lymphoproliferative disorders. Its clinical manifestations may include bleeding esophageal varices, ascites, or hepatic encephalopathy. In patients with hematological disorders, there are a number of potential causes of portal hypertension, including nodular regenerative hyperplasia of the liver (NRH). This lesion is characterized by diffuse replacement of normal hepatic parenchyma by multiple small nodules composed of regenerating hepatocytes with minimal or no fibrosis. This lack of fibrosis distinguishes NRH from cirrhosis. Unlike cirrhosis, NRH only rarely results in compromised hepatic synthetic function. The major manifestation is portal hypertension related to increased resistance to blood flow within hepatic sinusoids. NRH has been linked to a variety of systemic diseases including collagen vascular diseases, myeloproliferative and lymphoproliferative disorders, as well as various medications. Although NRH is commonly associated with blood dyscrasias, the diagnosis is overlooked because of the complexity and wide differential diagnosis of liver diseases in the setting of hematological malignancy. We review herein nodular regenerative hyperplasia of the liver, including aspects of epidemiology, pathogenesis, differential diagnosis, clinical course, and treatment. We highlight its association with different forms of hematological disease, aiming to increase the awareness of this entity to the internist and the treating hematologist/oncologist.
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Affiliation(s)
- Khalid A Al-Mukhaizeem
- Division of Gastroenterology, SMBD-Jewish General Hospital, McGill University, Montreal, Canada
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Sherker AH, Senosier M, Kermack D. Treatment of transfusion-dependent thalassemic patients infected with hepatitis C virus with interferon alpha-2b and ribavirin. Hepatology 2003; 37:223. [PMID: 12500209 DOI: 10.1053/jhep.2003.50037] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Al-Mukhaizeem KA, Lamoureux E, Rosenberg A, Sherker AH. Nodular regenerative hyperplasia of the liver and focal global glomerulosclerosis associated with sickle cell anemia. Dig Dis Sci 2002; 47:443-7. [PMID: 11855565 DOI: 10.1023/a:1013755029891] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Khalid A Al-Mukhaizeem
- Division of Gastroenterology, SMBD-Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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36
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Al-Mekhaizeem KA, Miriello M, Sherker AH. The frequency and significance of isolated hepatitis B core antibody and the suggested management of patients. CMAJ 2001; 165:1063-4. [PMID: 11699704 PMCID: PMC81543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Affiliation(s)
- K A Al-Mekhaizeem
- Division of Gastroenterology, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, Que
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37
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Abstract
Heparin-induced hepatotoxicity is well described in the literature, but rarely recognized clinically. Two cases were recently encountered. In the first case, elevated aminotransferase levels occurred after four days of heparin therapy. In the second case, enzyme levels increased after only 8 h of heparin treatment. To the authors' knowledge, this short time interval between the administration of heparin and liver enzyme elevations has not been described. The objective of this report is to increase the clinical awareness of this interesting and under-recognized biochemical observation.
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Affiliation(s)
- K A AL-Mekhaizeem
- Division of Gastroenterology, Sir Mortimer B Davis Jewish General Hospital, McGill University, Montreal, Canada
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38
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Baffis V, Shrier I, Sherker AH, Szilagyi A. Use of interferon for prevention of hepatocellular carcinoma in cirrhotic patients with hepatitis B or hepatitis C virus infection. Ann Intern Med 1999; 131:696-701. [PMID: 10577333 DOI: 10.7326/0003-4819-131-9-199911020-00011] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The incidence of hepatocellular carcinoma in North America is increasing. Current debate focuses on whether interferon administered to cirrhotic patients-with or without biochemical or virologic response-delays or prevents cancer of the liver. Review of the literature revealed several studies that showed improvement in or delay in progression of histologic fibrosis in patients with hepatitis C virus (HCV) infection. In patients with hepatitis B virus (HBV) infection, conversion to the nonreplicative stage may be associated with histologic improvement. However, only 11 studies (6 of HCV, 3 of HBV, and 2 of HCV and HBV) compared development of hepatocellular carcinoma in interferon-treated patients with cirrhosis and cirrhotic patients who were not treated with interferon. Although no firm statistical conclusions could be drawn, the literature suggests that interferon therapy may prevent hepatocellular carcinoma in patients with cirrhosis, particularly those infected with HCV. Interferon treatment cannot be recommended for all persons with cirrhosis and HBV or HCV infection because the current evidence is only suggestive. Long-term randomized, controlled trials may provide definitive data; however, it will be difficult, if not impossible, to conduct such trials because of the improved efficacy of combination therapy with interferon and ribavirin in patients with chronic HCV infection and the development of new therapies for patients with HBV infection.
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Affiliation(s)
- V Baffis
- Sir Mortimer B. Davis-Jewish General Hospital and McGill University, Montreal, Quebec, Canada
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39
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Fan Z, Yang QR, Twu JS, Sherker AH. Specific in vitro association between the hepatitis C viral genome and core protein. J Med Virol 1999; 59:131-4. [PMID: 10459145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Little is known about the molecular interactions required for hepatitis C virion assembly. The 5' noncoding region (5'NCR) of the RNA genome is highly conserved and has extensive secondary structure. The highly basic core protein is rich in arginine and lysine residues. We postulate that a specific interaction between these structures may be important for virion assembly. Using an RNA gel mobility shift assay, a specific interaction has been demonstrated between the RNA of the 5'NCR and recombinant core protein. Proteins from other regions of the virus do not interact with the viral RNA. The interaction is inhibited competitively by unlabelled sense polarity RNA, but antisense 5'NCR RNA and nonspecific RNAs compete only at much higher concentrations. These data suggest that there is a specific interaction between the 5'NCR of the hepatitis C virus (HCV) genome and HCV core protein. This interaction may be important for the specific encapsidation of the viral genome during HCV replication.
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Affiliation(s)
- Z Fan
- Lady Davis Institute for Medical Research, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montréal, Canada
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40
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41
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Affiliation(s)
- G Friedman
- Division of Gastroenterology, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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42
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Abstract
Cyproterone acetate is a normally well-tolerated drug that is used widely for the treatment of prostatic carcinoma. Liver toxicity due to its use is not well known. We describe two cases of fatal fulminant hepatitis related to the use of cyproterone acetate.
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Affiliation(s)
- G Friedman
- Department of Pathology, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Sherker AH, Twu JS, Reyes GR, Robinson WS. Presence of viral replicative intermediates in the liver and serum of patients infected with hepatitis C virus. J Med Virol 1993; 39:91-6. [PMID: 8387574 DOI: 10.1002/jmv.1890390203] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Hepatitis C virus (HCV) is a positive-polarity, single-stranded RNA virus, distantly related to the pestivirus and flavivirus genera. These viruses replicate through the formation of a minus-strand RNA intermediate, which encodes the positive-strand genome, which is subsequently encapsidated, enveloped, and released from infected cells. Minus-strand RNA is not found in the mature, circulating virions of flaviviruses. In an attempt to study the relative amounts of viral plus and minus strand in the liver and serum of HCV-infected individuals, we have developed a technique to amplify specifically each of the viral strands using a modified reverse transcriptase/polymerase chain reaction protocol on extracted RNA. Liver tumor and nontumor tissue from a patient with C-100-3 antibody was analyzed using this technique. In both cases, viral plus and minus strands were detected, although the plus-strand signal was several fold stronger than minus-strand signal by Southern hybridization. Sera from 11 C-100-3 antibody-positive patients with abnormal serum AIT levels were similarly analyzed. In all cases viral plus strand was detected, and in 10 of 11 cases viral minus strand was detected. The minus-strand signal was always much weaker than the plus-strand signal and the ratio of plus strand to minus strand varied among patients. No correlation was found between the level of minus strand detected or its ratio to plus strand with the level of serum transaminases or any other clinical parameter.
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Affiliation(s)
- A H Sherker
- Division of Infectious Diseases, Stanford University School of Medicine, California 94305
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44
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Affiliation(s)
- A H Sherker
- Department of Medicine, Stanford University, California 94305
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45
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Sherker AH, Heathcote J. Acute hepatitis in Crigler-Najjar syndrome. Am J Gastroenterol 1987; 82:883-5. [PMID: 3115090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We describe a 23-yr-old man with congenital unconjugated hyperbilirubinemia secondary to uridine diphosphate glucuronosyltransferase deficiency, and who cannot readily be classified as type I or type II Crigler-Najjar syndrome. After an episode of kernicterus in childhood he was treated with phenobarbital with a resultant marked decrease in his serum bilirubin concentration. Herein we describe his course after developing acute hepatitis secondary to infectious mononucleosis. He was treated acutely with plasmapheresis with prevention of any neurological sequelae despite having previously suffered from kernicterus.
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Hirota K, Sherker AH, Omata M, Yokosuka O, Okuda K. Effects of adenine arabinoside on serum and intrahepatic replicative forms of duck hepatitis B virus in chronic infection. Hepatology 1987; 7:24-8. [PMID: 3804202 DOI: 10.1002/hep.1840070107] [Citation(s) in RCA: 33] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Adenine arabinoside is an antiviral agent which has been used in a number of clinical studies for the treatment of chronic infections with hepatitis B virus. In order to better understand its effects and mode of action, we treated ducks chronically infected with duck hepatitis B virus with a 2-week course and monitored the effects of the drug on viral replication by studying duck hepatitis B virus DNA in liver and serum using molecular biological techniques. We found the drug to be effective in ducks only at much higher doses than those used in humans. At high doses, adenine arabinoside had a dose-related inhibitory effect on viral replication during treatment, but there was a rapid return toward baseline values soon after the cessation of treatment. The supercoiled form of viral DNA was found to be most resistant to adenine arabinoside therapy, and the drug had a disproportionate inhibitory effect on viral plus (noncoding) strand synthesis. We conclude that adenine arabinoside likely exerts its effect in hepadna virus infections predominantly through inhibition of viral DNA polymerase. On the basis of our current study and previous trials in hepatitis B virus-infected patients, we predict that adenine arabinoside will not efficiently eliminate viral replication in chronic hepadna virus infection, when used as the sole therapeutic modality. Adenine arabinoside may have a role to play as an adjunct to immunomodulation or interferon therapy in chronic hepatitis B virus infection in man.
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Abstract
Foscarnet (trisodium phosphonoformate) is a new antiviral compound with in vitro inhibitory effects against the DNA polymerases of hepadna viruses. To study the effects of the drug in chronic hepadna virus infection, we treated ducks chronically infected with duck hepatitis B virus for 10 days with either low-dose foscarnet (50 mg/kg i.p. b.i.d.), high-dose foscarnet (250 mg/kg i.p. b.i.d.), or sterile water injections. Serum duck hepatitis B virus DNA and intrahepatic replicative forms of the virus were measured using molecular biological techniques with both a double-stranded radiolabeled DNA probe and a plus-strand (noncoding) specific RNA probe. We found a dose-related decrease in serum and intrahepatic duck hepatitis B virus DNA during treatment, with a rapid return toward baseline values after the cessation of treatment. There was a disproportionate decrease in the plus strand of viral DNA with treatment. We conclude that foscarnet exerts its effect in hepadna virus infection through inhibition of viral DNA polymerase. Further study is necessary to determine whether foscarnet, by itself or in combination with other treatment modalities, has a role to play in the treatment of chronic hepatitis B infections in humans.
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Hirota K, Sherker AH, Omata M, Yokosuka O, Okuda K. Effects of adenine arabinoside and corticosteroid on replication of duck hepatitis B virus DNA in the liver. Ann Acad Med Singap 1986; 15:227-32. [PMID: 3752897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Adenine arabinoside (Ara-A) therapy and abrupt withdrawal of corticosteroids have both been used in the treatment of chronic infections due to hepatitis B virus (HBV). In order to better understand the effects and mechanism of action of these treatments, we treated ducks chronically infected with duck hepatitis B virus (DHBV) with different dosage regimens of the two therapies. We measured endogenous DNA polymerase activity and used sensitive molecular biological techniques to monitor serum and intrahepatic viral replicative forms during and after drug treatment. Ara-A had a transient, dose related inhibitory effect on DHBV replication. Viral plus strand synthesis was disproportionately affected. Following the cessation of Ara-A treatment markers of viral replication returned to their baseline values. We conclude that Ara-A exerts its effect through inhibition of viral DNA polymerase. Corticosteroid treatment results in an increase in DHBV replication, but steroid withdrawal results in a short-lived transient decrease in markers of viral replication to below pretreatment values. Our results suggest that steroid withdrawal decreases hepadna virus replication through a mechanisms of immune modulation. On the basis of these results and previous trials in HBV infected patients, we predict that neither agent will efficiently eliminate viral replication in chronic hepadna virus infection when used as the sole therapeutic modality. We suggest that the differences in the mechanisms of action of Ara-A treatment and corticosteroid withdrawal be exploited, and the use of combination therapy be explored.
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