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Jarasvaraparn C, Vilar-Gomez E, Yates KP, Wilson LA, Neuschwander-Tetri B, Loomba R, Cummings O, Vos M, Xanthakos S, Schwimmer J, Molleston JP, Sanyal A, Tonascia J, Chalasani N. Age, BMI, and Type 2 Diabetes Modify the Relationship Between PNPLA3 and Advanced Fibrosis in Children and Adults With NAFLD. Clin Gastroenterol Hepatol 2024; 22:1024-1036.e2. [PMID: 38145725 PMCID: PMC11045318 DOI: 10.1016/j.cgh.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 09/21/2023] [Revised: 11/23/2023] [Accepted: 12/04/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND & AIMS PNPLA3 G-allele is an important determinant of disease severity in nonalcoholic fatty liver disease (NAFLD). Here, we investigated the effect of age, body mass index (BMI), and type 2 diabetes mellitus (T2DM) on the relationship between PNPLA3 G-allele and advanced fibrosis in adults and children with histologically characterized NAFLD. METHODS A total of 1047 children and 2057 adults were included. DNA was genotyped for rs738409 in duplicate. Primary outcome of interest was advanced fibrosis (fibrosis stage ≥3). Regression analyses were performed after controlling for relevant covariates. An additive model was used to assess the effect of PNPLA3 G-allele (CC vs CG vs GG). RESULTS PNPLA3 G-allele was significantly associated with advanced fibrosis in children (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.16-2.09) and adults (OR, 1.55; 95% CI, 1.16-1.54). Across the cohort, older age significantly increased the risk for advanced fibrosis for PNPLA3 CC (OR, 1.019; 95% CI, 1.013-1.026), CG (OR, 1.024; 95% CI, 1.018-1.030), and GG (OR, 1.03; 95% CI, 1.023-1.037) genotypes. BMI significantly increased the relationship between PNPLA3 genotypes and advanced fibrosis in children and adults. A BMI of 30 kg/m2 was the cutoff beyond which PNPLA3 G-allele had exponential effect on the risk for advanced fibrosis in children and adults. T2DM significantly worsened the relationship between PNPLA3 G-allele and advanced fibrosis in children and adults (interaction P < .01 for both). CONCLUSIONS Age, BMI, and T2DM modify the risk of advanced fibrosis associated with PNPLA3 G-allele. Preventing or reversing T2DM and obesity in persons carrying PNPLA3 G-allele may lower the risk for advanced fibrosis in NAFLD.
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Affiliation(s)
- Chaowapong Jarasvaraparn
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana
| | - Eduardo Vilar-Gomez
- Division of Gastroenterology, and Hepatology, Indiana University School of Medicine, Indiana University Health, Indianapolis, Indiana
| | - Katherine P Yates
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Laura A Wilson
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | | | - Rohit Loomba
- Division of Gastroenterology, Hepatology, and Nutrition, University of California, San Diego School of Medicine, La Jolla, California
| | - Oscar Cummings
- Division of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Miriam Vos
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Stavra Xanthakos
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jeffrey Schwimmer
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California; Department of Gastroenterology, Rady Children's Hospital San Diego, San Diego, California
| | - Jean P Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana
| | - Arun Sanyal
- Division of Gastroenterology, and Hepatology, Virginia Commonwealth University, Richmond, Virginia
| | - James Tonascia
- Department of Biostatistics and Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Naga Chalasani
- Division of Gastroenterology, and Hepatology, Indiana University School of Medicine, Indiana University Health, Indianapolis, Indiana.
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Protich HE, Molleston JP, Bozic M, Pettit RS. Elexacaftor/Tezacaftor/Ivacaftor use in Pediatric Cystic Fibrosis Patients with Advanced Liver Disease. J Cyst Fibros 2024:S1569-1993(24)00040-7. [PMID: 38580564 DOI: 10.1016/j.jcf.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/29/2023] [Revised: 02/29/2024] [Accepted: 03/19/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy extends the life expectancy of people with cystic fibrosis (PwCF). However, CFTR modulators have not been well studied in patients with cystic fibrosis liver disease (CFLD), specifically those with advanced liver disease with portal hypertension. The purpose of this report is to describe the use of elexacaftor/tezacaftor/ivacaftor (ETI) in pediatric CF patients with advanced CFLD. METHODS This retrospective case series included PwCF < 18 years old with baseline advanced CFLD initiated on ETI. RESULTS Eleven PwCF and advanced CFLD were treated with ETI; six started a reduced dose regimen. No patient required treatment interruption and four patients received dose changes related to increase in transaminase and/or bilirubin elevations. Mean (SD) change in ppFEV1 from prior to ETI to highest value during therapy was 14.27 % (4.25) (p = 0.007). When evaluating the group as whole, AST decreased from baseline to last reported -15.18 (23.23) units/L (p = 0.054) and ALT slightly increased 0.73 (39.13) units/L (p = 0.96). Bilirubin increased minimally overall for patients with mean change from baseline of 0.83 (1.33) mg/dL [range -0.5-3] (p = 0.17). A model for time on ETI showed a significant decrease in AST over time of 0.955 per month of ETI but no other liver biochemistries were significant. No patient experienced decompensation of CFLD. CONCLUSION ETI therapy in pediatric CF patients with advanced CFLD can be beneficial in improving pulmonary and nutritional outcomes without negative impact on liver biochemistries or hepatic outcomes. Close monitoring is recommended to ensure safety and tolerability.
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Affiliation(s)
- Hannah E Protich
- Department of Pharmacy, Riley Hospital for Children at IU Health, 705 Riley Hospital Drive, Simon Family Tower W6111, Indianapolis, IN, USA.
| | - Jean P Molleston
- Department of Pediatric Gastroenterology, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 4210, Indianapolis, Indiana, USA
| | - Molly Bozic
- Department of Pediatric Gastroenterology, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 4210, Indianapolis, Indiana, USA
| | - Rebecca S Pettit
- Department of Pharmacy, Riley Hospital for Children at IU Health, 705 Riley Hospital Drive, Simon Family Tower W6111, Indianapolis, IN, USA
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Pandurangi S, Mourya R, Nalluri S, Fei L, Dong S, Harpavat S, Guthery SL, Molleston JP, Rosenthal P, Sokol RJ, Wang KS, Ng V, Alonso EM, Hsu EK, Karpen SJ, Loomes KM, Magee JC, Shneider BL, Horslen SP, Teckman JH, Bezerra JA. Diagnostic accuracy of serum matrix metalloproteinase-7 as a biomarker of biliary atresia in a large North American cohort. Hepatology 2024:01515467-990000000-00787. [PMID: 38446707 DOI: 10.1097/hep.0000000000000827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/20/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND AND AIMS High levels of serum matrix metalloproteinase-7 (MMP-7) have been linked to biliary atresia (BA), with wide variation in concentration cutoffs. We investigated the accuracy of serum MMP-7 as a diagnostic biomarker in a large North American cohort. APPROACH AND RESULTS MMP-7 was measured in serum samples of 399 infants with cholestasis in the Prospective Database of Infants with Cholestasis study of the Childhood Liver Disease Research Network, 201 infants with BA and 198 with non-BA cholestasis (age median: 64 and 59 days, p = 0.94). MMP-7 was assayed on antibody-bead fluorescence (single-plex) and time resolved fluorescence energy transfer assays. The discriminative performance of MMP-7 was compared with other clinical markers. On the single-plex assay, MMP-7 generated an AUROC of 0.90 (CI: 0.87-0.94). At cutoff 52.8 ng/mL, it produced sensitivity = 94.03%, specificity = 77.78%, positive predictive value = 64.46%, and negative predictive value = 96.82% for BA. AUROC for gamma-glutamyl transferase = 0.81 (CI: 0.77-0.86), stool color = 0.68 (CI: 0.63-0.73), and pathology = 0.84 (CI: 0.76-0.91). Logistic regression models of MMP-7 with other clinical variables individually or combined showed an increase for MMP-7+gamma-glutamyl transferase AUROC to 0.91 (CI: 0.88-0.95). Serum concentrations produced by time resolved fluorescence energy transfer differed from single-plex, with an optimal cutoff of 18.2 ng/mL. Results were consistent within each assay technology and generated similar AUROCs. CONCLUSIONS Serum MMP-7 has high discriminative properties to differentiate BA from other forms of neonatal cholestasis. MMP-7 cutoff values vary according to assay technology. Using MMP-7 in the evaluation of infants with cholestasis may simplify diagnostic algorithms and shorten the time to hepatoportoenterostomy.
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Affiliation(s)
- Sindhu Pandurangi
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Reena Mourya
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Shreya Nalluri
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lin Fei
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Shun Dong
- University of Kansas School of Business, Lawrence, Kansas, USA
| | - Sanjiv Harpavat
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Houston, Texas, USA
| | - Stephen L Guthery
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Utah and Intermountain Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Jean P Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Philip Rosenthal
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of California, San Francisco, California, USA
| | - Ronald J Sokol
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Kasper S Wang
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vicky Ng
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Estella M Alonso
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Evelyn K Hsu
- Division of Pediatric Gastroenterology and Hepatology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington, USA
| | - Saul J Karpen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John C Magee
- Division of Transplant Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Simon P Horslen
- Division of Pediatric Gastroenterology, UPMC Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Jeffrey H Teckman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatrics, Cardinal Glennon Children's Hospital, Saint Louis, Missouri, USA
| | - Jorge A Bezerra
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Shaheen M, Lei GS, Relich RF, Jarasvaraparn C, Tolliver KM, Molleston JP, González IA. Granulomas in Pediatric Liver Biopsies: Single Center Experience. Pediatr Dev Pathol 2024:10935266231221908. [PMID: 38221675 DOI: 10.1177/10935266231221908] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 01/16/2024]
Abstract
BACKGROUND Granulomas in pediatric liver biopsies (GPLB) are rare with the largest pediatric cohort reported over 25 years ago. METHODS Single-center retrospective study of GPLB. RESULTS Seventeen liver biopsies from 16 patients with granulomas were identified (9 boys, 56%) with a median age of 13 years (range: 1-18) for which the most common indication was the presence of a nodule/mass (47%). Significant comorbidities were seen in 13 patients (81%) and included: liver transplant (25%), history of a neoplasm (25%), autoimmune hepatitis (6%), Crohn disease (6%), bipolar disorder (6%), severe combined immunodeficiency (6%), and sickle cell disease (6%). Eleven patients were taking multiple medications at the time of biopsy. Granulomas were more commonly pan-acinar (11 cases) followed by subcapsular (4 cases), portal (1 case), and periportal (1 case). Necrosis was seen in 10 cases (59%). GMS stain was positive in 2 cases for Histoplasma-like yeast; microbiological cultures were negative in all cases (no: 4). A 18S and 16S rRNA gene sequencing performed in 15 cases revealed only 1 with a pathogenic microorganism, Mycobacterium angelicum. CONCLUSION In our experience, GPLB are heterogenous with only 3 cases having an identifiable infectious etiology and many of the remaining cases being associated to multiple medications, suggesting drug-induced liver injury as possible etiology.
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Affiliation(s)
- Muhammad Shaheen
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Guang-Sheng Lei
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ryan F Relich
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chaowapong Jarasvaraparn
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kyla M Tolliver
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jean P Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Iván A González
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Jarasvaraparn C, Thoe J, Rodenbarger A, Masuoka H, Payne RM, Markham LW, Molleston JP. Biomarkers of fibrosis and portal hypertension in Fontan-associated liver disease in children and adults. Dig Liver Dis 2024:S1590-8658(23)01123-4. [PMID: 38220486 DOI: 10.1016/j.dld.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 09/04/2023] [Revised: 11/19/2023] [Accepted: 12/29/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Fontan-associated liver disease (FALD) refers to structural and functional changes of the liver caused by the physiology of the Fontan palliation. Currently, liver biopsy is the gold standard to assess liver fibrosis of FALD. AIM Investigate biomarkers correlating with severity of liver biopsy fibrosis in FALD. METHODS A retrospective study of post-Fontan patients ≥ 10 years of age who underwent liver biopsy was conducted. Advanced liver disease (ALD) was defined as bridging fibrosis and/or cirrhosis on liver biopsy. AST-to-platelet ratio index (APRI), Fibrosis-4 (FIB-4) and Liver Stiffness Measurement (LSM) from FibroScan were used as non-invasive fibrosis scores. RESULTS Sixty-six patients (26/47; 55.3% adults and 13/19 children; 68.4%) had ALD on biopsy. ALD was associated with lower platelet count (151 vs. 198 K/uL, p = 0.003), higher APRI (0.64 vs. 0.32, p = 0.01), higher FIB-4 (0.64 vs. 0.32, p = 0.02). Liver fibrosis score correlated with APRI (0.34, p = 0.02) and FIB-4 (0.47, p = 0.001) in adults. LSM had a high sensitivity at 81.3% with 45.5% specificity at a cut-off 18.5 kPa. CONCLUSIONS APRI and FIB-4 had modest discrimination to identify adults with advanced liver disease, but not children, indicating that these values may be followed as a marker of FALD progression in older patients.
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Affiliation(s)
- Chaowapong Jarasvaraparn
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University, 705 Riley Hospital Drive, ROC 4210, Indianapolis, Indiana 46202, United States.
| | | | | | - Howard Masuoka
- Division of Gastroenterology, Hepatology and Nutrition Riley Hospital for Children at IU Health, Indiana University School of Medicine, United States
| | | | | | - Jean P Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University, 705 Riley Hospital Drive, ROC 4210, Indianapolis, Indiana 46202, United States
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Van Hove JL, Friederich MW, Strode DK, Van Hove RA, Miller KR, Sharma R, Shah H, Estrella J, Gabel L, Horslen S, Kohli R, Lovell MA, Miethke AG, Molleston JP, Romero R, Squires JE, Alonso EM, Guthery SL, Kamath BM, Loomes KM, Rosenthal P, Mysore KR, Cavallo LA, Valentino PL, Magee JC, Sundaram SS, Sokol RJ. Protein biomarkers GDF15 and FGF21 to differentiate mitochondrial hepatopathies from other pediatric liver diseases. Hepatol Commun 2024; 8:e0361. [PMID: 38180987 PMCID: PMC10781130 DOI: 10.1097/hc9.0000000000000361] [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] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/17/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Mitochondrial hepatopathies (MHs) are primary mitochondrial genetic disorders that can present as childhood liver disease. No recognized biomarkers discriminate MH from other childhood liver diseases. The protein biomarkers growth differentiation factor 15 (GDF15) and fibroblast growth factor 21 (FGF21) differentiate mitochondrial myopathies from other myopathies. We evaluated these biomarkers to determine if they discriminate MH from other liver diseases in children. METHODS Serum biomarkers were measured in 36 children with MH (17 had a genetic diagnosis); 38 each with biliary atresia, α1-antitrypsin deficiency, and Alagille syndrome; 20 with NASH; and 186 controls. RESULTS GDF15 levels compared to controls were mildly elevated in patients with α1-antitrypsin deficiency, Alagille syndrome, and biliary atresia-young subgroup, but markedly elevated in MH (p<0.001). FGF21 levels were mildly elevated in NASH and markedly elevated in MH (p<0.001). Both biomarkers were higher in patients with MH with a known genetic cause but were similar in acute and chronic presentations. Both markers had a strong performance to identify MH with a molecular diagnosis with the AUC for GDF15 0.93±0.04 and for FGF21 0.90±0.06. Simultaneous elevation of both markers >98th percentile of controls identified genetically confirmed MH with a sensitivity of 88% and specificity of 96%. In MH, independent predictors of survival without requiring liver transplantation were international normalized ratio and either GDF15 or FGF21 levels, with levels <2000 ng/L predicting survival without liver transplantation (p<0.01). CONCLUSIONS GDF15 and FGF21 are significantly higher in children with MH compared to other childhood liver diseases and controls and, when combined, were predictive of MH and had prognostic implications.
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Affiliation(s)
- Johan L.K. Van Hove
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora, Colorado, USA
- Department of Pathology and Laboratory Medicine, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Marisa W. Friederich
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora, Colorado, USA
- Department of Pathology and Laboratory Medicine, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Dana K. Strode
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Roxanne A. Van Hove
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Kristen R. Miller
- Section of Endocrinology, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Rohit Sharma
- Department of Molecular Biology and Department of Medicine, Howard Hughes Medical Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Systems Biology, Harvard Medical School, Boston, Massachusetts, USA
- Broad Institute, Cambridge, Massachusetts, USA
| | - Hardik Shah
- Department of Molecular Biology and Department of Medicine, Howard Hughes Medical Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jane Estrella
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora, Colorado, USA
- Department of Neurosciences, University of California San Diego, San Diego, California, USA
| | - Linda Gabel
- Department of Pathology and Laboratory Medicine, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Simon Horslen
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rohit Kohli
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Mark A. Lovell
- Department of Pathology and Laboratory Medicine, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Alexander G. Miethke
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jean P. Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University and Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Rene Romero
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - James E. Squires
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Estella M. Alonso
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Ann and Robert H. Lurie Children’s Hospital, Chicago, Illinois, USA
| | - Stephen L. Guthery
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Spencer F. Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
- Intermountain Primary Children’s Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kathleen M. Loomes
- Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Philip Rosenthal
- Departments of Pediatrics and Surgery, University of California San Francisco, San Francisco, California, USA
| | - Krupa R. Mysore
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas, USA
| | - Laurel A. Cavallo
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas, USA
| | - Pamela L. Valentino
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital, University of Washington, Seattle, Washington, USA
| | - John C. Magee
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Shikha S. Sundaram
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Ronald J. Sokol
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora, Colorado, USA
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7
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Jain AK, Buchannan P, Yates KP, Belt P, Schwimmer JB, Rosenthal P, Murray KF, Molleston JP, Scheimann A, Xanthakos SA, Behling CA, Hertel P, Nilson J, Neuschwander-Tetri BA, Tonascia J, Vos MB. Nutrition assessment and MASH severity in children using the Healthy Eating Index. Hepatol Commun 2023; 7:e0320. [PMID: 38055641 PMCID: PMC10984667 DOI: 10.1097/hc9.0000000000000320] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/19/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Pediatric metabolic-associated fatty liver disease (MAFLD) is a global health problem, with lifestyle modification as its major therapeutic strategy. Rigorous characterization of dietary content on MAFLD in children is lacking. We hypothesized an objectively measured healthier diet would positively modulate MAFLD. METHODS Diet was assessed using the Nutrition Data System for Research in children enrolled from 10 tertiary clinical centers to determine the Healthy Eating Index (HEI, 0-100) and individual food components. RESULTS In all, 119 children were included (13.3 ± 2.7 y), 80 (67%) male, 67 (18%) White, and 90 (76%) Hispanic, with an average body mass index Z-score of 2.2 ± 0.5. Diet was classified as low HEI < 47.94 (n = 39), mid HEI ≥ 47.94 and < 58.89 (n = 41), or high HEI ≥ 58.89 (n=39). Children with high HEI (healthier diet) had lower body weight (p = 0.005) and more favorable lipids. Mean serum triglycerides for low, mid, and high HEI were 163, 148, and 120 mg/dL, respectively; p = 0.04 mid versus high, p = 0.01 low versus high. Mean HDL was 38, 41 and 43 mg/dL; p = 0.02 low vs high. Less severe steatosis was noted with added sugar ≤ 10% of calories (p = 0.03). Higher lobular inflammation is associated with a higher percentage of calories from fat (OR (95% CI) = 0.95 (0.91-1.00), p = 0.04). CONCLUSIONS In children with MAFLD, high HEI is associated with lower body weight and more favorable lipids, while added sugar and fat intake has individual histologic features. Differential consumption of major dietary components may modify both metabolic risk factors and histologic liver injury, highlighting the importance of objective diet assessments in children with MAFLD.
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Affiliation(s)
- Ajay Kumar Jain
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Saint Louis University, St. Louis, Missouri, USA
| | - Paula Buchannan
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Saint Louis University, St. Louis, Missouri, USA
| | - Katherine P. Yates
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Patricia Belt
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jeffrey B. Schwimmer
- Department of Pediatrics, Division of Gastroenterology, UC San Diego, La Jolla, California, USA
- Department of Gastroenterology, Rady Children’s Hospital, San Diego, California, USA
| | - Philip Rosenthal
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California, San Francisco Benioff Children’s Hospital, San Francisco, California, USA
| | - Karen F. Murray
- Pediatrics Institute, Cleveland Clinic and Cleveland Clinic Children’s Hospital, Cleveland, Ohio
| | - Jean P. Molleston
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Ann Scheimann
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins University, Baltimore, Maryland, USA
| | - Stavra A. Xanthakos
- Steatohepatitis Center, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Cynthia A. Behling
- Department of Pediatrics, Division of Gastroenterology, UC San Diego, La Jolla, California, USA
- Department of Gastroenterology and Pacific Rim Pathology, San Diego, California, USA
| | - Paula Hertel
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Jamie Nilson
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Saint Louis University, St. Louis, Missouri, USA
| | | | - James Tonascia
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Miriam B. Vos
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
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8
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Teckman J, Rosenthal P, Ignacio RV, Spino C, Bass LM, Horslen S, Wang K, Magee JC, Karpen S, Asai A, Molleston JP, Squires RH, Kamath BM, Guthery SL, Loomes KM, Shneider BL, Sokol RJ. Neonatal cholestasis in children with Alpha-1-AT deficiency is a risk for earlier severe liver disease with male predominance. Hepatol Commun 2023; 7:e0345. [PMID: 38055647 PMCID: PMC10984655 DOI: 10.1097/hc9.0000000000000345] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/27/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Our objective was to better understand the natural history and disease modifiers of Alpha-1-antitrypsin deficiency (AATD), a common genetic liver disease causing hepatitis and cirrhosis in adults and children. The clinical course is highly variable. Some infants present with neonatal cholestasis, which can resolve spontaneously or progress to cirrhosis; others are well in infancy, only to develop portal hypertension later in childhood. METHODS The Childhood Liver Disease Research Network has been enrolling AATD participants into longitudinal, observational studies at North American tertiary centers since 2004. We examined the clinical courses of 2 subgroups of participants from the several hundred enrolled; first, those presenting with neonatal cholestasis captured by a unique study, enrolled because of neonatal cholestasis but before specific diagnosis, then followed longitudinally (n=46); second, separately, all participants who progressed to liver transplant (n=119). RESULTS We found male predominance for neonatal cholestasis in AATD (65% male, p=0.04), an association of neonatal gamma-glutamyl transpeptidase elevation to more severe disease, and a higher rate of neonatal cholestasis progression to portal hypertension than previously reported (41%) occurring at median age of 5 months. Participants with and without preceding neonatal cholestasis were at risk of progression to transplant. Participants who progressed to liver transplant following neonatal cholestasis were significantly younger at transplant than those without neonatal cholestasis (4.1 vs. 7.8 years, p=0.04, overall range 0.3-17 years). Neonatal cholestasis had a negative impact on growth parameters. Coagulopathy and varices were common before transplant, but gastrointestinal bleeding was not. CONCLUSIONS Patients with AATD and neonatal cholestasis are at risk of early progression to severe liver disease, but the risk of severe disease extends throughout childhood. Careful attention to nutrition and growth is needed.
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Affiliation(s)
- Jeffrey Teckman
- Department of Pediatrics and Biochemistry, Saint Louis University, Cardinal Glennon Children’s Hospital, Saint Louis, Missouri, USA
| | - Philip Rosenthal
- Department of Pediatrics and Surgery, University of California San Francisco, San Francisco, California, USA
| | | | - Cathie Spino
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Lee M. Bass
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Simon Horslen
- Department of Pediatric Gastroenterology and Hepatology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kasper Wang
- Department of Pediatric Gastroenterology, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - John C. Magee
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Saul Karpen
- Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Akihiro Asai
- Department of Gastroenterology, and Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jean P. Molleston
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Robert H. Squires
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Binita M. Kamath
- Division of Pediatric Gastroenterology, Department of Pediatrics, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Stephen L. Guthery
- Department of Pediatrics, University of Utah College of Medicine and Intermountain Primary Children’s Hospital, Salt Lake City, Utah, USA
| | - Kathleen M. Loomes
- Division of Pediatric Gastroenterology, Department of Pediatrics, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Benjamin L. Shneider
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, USA
| | - Ronald J. Sokol
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, Colorado, USA
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9
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Boster JM, Goodrich NP, Spino C, Loomes KM, Alonso EM, Kamath BM, Sokol RJ, Karpen S, Miethke A, Shneider BL, Molleston JP, Kohli R, Horslen SP, Rosenthal P, Valentino PL, Teckman JH, Hangartner TN, Sundaram SS. Sarcopenia is associated with osteopenia and impaired quality of life in children with genetic intrahepatic cholestatic liver disease. Hepatol Commun 2023; 7:e0293. [PMID: 37902507 PMCID: PMC10617863 DOI: 10.1097/hc9.0000000000000293] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 07/18/2023] [Accepted: 08/24/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Sarcopenia occurs in pediatric chronic liver disease, although the prevalence and contributing factors in genetic intrahepatic cholestasis are not well-described. The objective of this study was to measure muscle mass in school-aged children with genetic intrahepatic cholestasis and assess relationships between sarcopenia, clinical variables, and outcomes. METHODS Estimated skeletal muscle mass (eSMM) was calculated on dual-energy x-ray absorptiometry obtained in a Childhood Liver Disease Research Network study of children with bile acid synthesis disorders(BASD) alpha-1 antitrypsin deficiency (a1ATd), chronic intrahepatic cholestasis (CIC), and Alagille syndrome (ALGS). Relationships between eSMM, liver disease, and transplant-free survival were assessed. RESULTS eSMM was calculated in 127 participants (5-18 y): 12 BASD, 41 a1ATd, 33 CIC, and 41 ALGS. eSMM z-score was lower in CIC (-1.6 ± 1.3) and ALGS (-2.1 ± 1.0) than BASD (-0.1 ± 1.1) and a1ATd (-0.5 ± 0.8, p < 0.001). Sarcopenia (defined as eSMM z-score ≤- 2) was present in 33.3% of CIC and 41.5% of ALGS participants. eSMM correlated with bone mineral density in the 4 disease groups (r=0.52-0.55, p < 0.001-0.07), but not serum bile acids, bilirubin, aspartate aminotransferase/platelet ratio index, or clinically evident portal hypertension. Of the 2 patients who died (1 with sarcopenia) and 18 who underwent liver transplant (LT, 4 with sarcopenia), eSMM z-score did not predict transplant-free survival. eSMM z-score correlated with the Physical Pediatric Quality of Life Inventory score (r=0.38-0.53, p = 0.007-0.04) in CIC and a1ATd. CONCLUSION Severe sarcopenia occurs in some children with ALGS and CIC. The lack of correlation between eSMM and biochemical cholestasis suggests mechanisms beyond cholestasis contribute to sarcopenia. While sarcopenia did not predict transplant-free survival, LT and death were infrequent events. Future studies may define mechanisms of sarcopenia in genetic intrahepatic cholestasis.
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Affiliation(s)
- Julia M. Boster
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Cathie Spino
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Kathleen M. Loomes
- Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Binita M. Kamath
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ronald J. Sokol
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Saul Karpen
- Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | | | | | - Rohit Kohli
- Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Simon P. Horslen
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Philip Rosenthal
- UCSF Benioff Children’s Hospital, San Francisco, California, USA
| | | | | | - Thomas N. Hangartner
- Department of Biomedical, Industrial & Human Factors Engineering, Wright State University, Dayton, Ohio, USA
| | - Shikha S. Sundaram
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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10
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Wang A, Blackford AL, Behling C, Wilson LA, Newton KP, Xanthakos SA, Fishbein MH, Vos MB, Mouzaki M, Molleston JP, Jain AK, Hertel P, Harlow Adams K, Schwimmer JB. Development of Fibro-PeN, a clinical prediction model for moderate-to-severe fibrosis in children with nonalcoholic fatty liver disease. Hepatology 2023:01515467-990000000-00609. [PMID: 37870272 PMCID: PMC11035485 DOI: 10.1097/hep.0000000000000644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/23/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND AND AIMS Liver fibrosis is common in children with NAFLD and is an important determinant of outcomes. High-performing noninvasive models to assess fibrosis in children are needed. The objectives of this study were to evaluate the performance of existing pediatric and adult fibrosis prediction models and to develop a clinical prediction rule for identifying moderate-to-severe fibrosis in children with NAFLD. APPROACH AND RESULTS We enrolled children with biopsy-proven NAFLD in the Nonalcoholic Steatohepatitis Clinical Research Network within 90 days of liver biopsy. We staged liver fibrosis in consensus using the Nonalcoholic Steatohepatitis Clinical Research Network scoring system. We evaluated existing pediatric and adult models for fibrosis and developed a new pediatric model using the least absolute shrinkage and selection operator with linear and spline terms for discriminating moderate-to-severe fibrosis from none or mild fibrosis. The model was internally validated with 10-fold cross-validation. We evaluated 1055 children with NAFLD, of whom 26% had moderate-to-severe fibrosis. Existing models performed poorly in classifying fibrosis in children, with area under the receiver operator curves (AUC) ranging from 0.57 to 0.64. In contrast, our new model, fibrosis in pediatric NAFLD was derived from fourteen common clinical variables and had an AUC of 0.79 (95% CI: 0.77-0.81) with 72% sensitivity and 76% specificity for identifying moderate-to-severe fibrosis. CONCLUSION Existing fibrosis prediction models have limited clinical utility in children with NAFLD. Fibrosis in pediatric NAFLD offers improved performance characteristics for risk stratification by identifying moderate-to-severe fibrosis in children with NAFLD.
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Affiliation(s)
- Andrew Wang
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, California, USA
- Department of Gastroenterology, Rady Children's Hospital, San Diego, California, USA
| | - Amanda L Blackford
- Department of Oncology, Division of Quantitative Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cynthia Behling
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Laura A Wilson
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kimberly P Newton
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, California, USA
- Department of Gastroenterology, Rady Children's Hospital, San Diego, California, USA
| | - Stavra A Xanthakos
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Mark H Fishbein
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Miriam B Vos
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Marialena Mouzaki
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jean P Molleston
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ajay K Jain
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Saint Louis University, St. Louis, Missouri, USA
| | - Paula Hertel
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kathryn Harlow Adams
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jeffrey B Schwimmer
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, California, USA
- Department of Gastroenterology, Rady Children's Hospital, San Diego, California, USA
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11
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Towbin AJ, Ye W, Huang S, Karmazyn BW, Molleston JP, Masand P, Leung DH, Chang S, Narkewicz MR, Alazraki AL, Freeman AJ, Otto RK, Green N, Kamel IR, Karnsakul WW, Magee JC, Tkach J, Palermo JJ. Prospective study of quantitative liver MRI in cystic fibrosis: feasibility and comparison to PUSH cohort ultrasound. Pediatr Radiol 2023; 53:2210-2220. [PMID: 37500799 DOI: 10.1007/s00247-023-05706-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/20/2022] [Revised: 06/08/2023] [Accepted: 06/17/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Pediatric radiologists can identify a liver ultrasound (US) pattern predictive of progression to advanced liver disease. However, reliably discriminating these US patterns remains difficult. Quantitative magnetic resonance imaging (MRI) may provide an objective measure of liver disease in cystic fibrosis (CF). OBJECTIVE The purpose of this study was to determine if quantitative MRI, including MR elastography, is feasible in children with CF and to determine how quantitative MRI-derived metrics compared to a research US. MATERIALS AND METHODS A prospective, multi-institutional trial was performed evaluating CF participants who underwent a standardized MRI. At central review, liver stiffness, fat fraction, liver volume, and spleen volume were obtained. Participants whose MRI was performed within 1 year of US were classified by US pattern as normal, homogeneous hyperechoic, heterogeneous, or nodular. Each MRI measure was compared among US grade groups using the Kruskal-Wallis test. RESULTS Ninety-three participants (51 females [54.8%]; mean 15.6 years [range 8.1-21.7 years]) underwent MRI. MR elastography was feasible in 87 participants (93.5%). Fifty-eight participants had an US within 1 year of MRI. In these participants, a nodular liver had significantly higher stiffness (P<0.01) than normal or homogeneous hyperechoic livers. Participants with a homogeneous hyperechoic liver had a higher fat fraction (P<0.005) than others. CONCLUSION MR elastography is feasible in children with CF. Participants with a nodular pattern had higher liver stiffness supporting the US determination of advanced liver disease. Participants with a homogeneous hyperechoic pattern had higher fat fractions supporting the diagnosis of steatosis.
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Affiliation(s)
- Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital, 3333 Burnet Avenue, MLC 5031, Cincinnati, OH, 45229, USA.
- Department of Radiology, University of Cincinnati School of Medicine, Cincinnati, OH, USA.
| | - Wen Ye
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Suiyuan Huang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Boaz W Karmazyn
- Pediatric Radiology, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Prakash Masand
- Division of Radiology, Texas Children's Hospital, Houston, TX, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's, Baylor College of Medicine, Houston, TX, USA
| | - Samuel Chang
- Department of Radiology, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - 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, USA
| | - Adina L Alazraki
- Department of Radiology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Randolph K Otto
- Department of Radiology, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Nicole Green
- Division of Gastroenterology and Hepatology, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Ihab R Kamel
- Department of Radiology, John Hopkins School of Medicine, Baltimore, MD, USA
| | - Wikrom W Karnsakul
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, John Hopkins School of Medicine, Baltimore, MD, USA
| | - John C Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jean Tkach
- Department of Radiology, Cincinnati Children's Hospital, 3333 Burnet Avenue, MLC 5031, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Joseph J Palermo
- Division of Pediatric, Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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12
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Siegel MJ, Leung DH, Molleston JP, Ye W, Paranjape SM, Freeman AJ, Palermo JJ, Stoll J, Masand P, Karmazyn B, Harned R, Ling SC, Navarro OM, Karnsakul W, Alazraki A, Schwarzenberg SJ, Towbin AJ, Alonso EM, Nicholas JL, Green N, Otto RK, Magee JC, Narkewicz MR. Heterogeneous liver on research ultrasound identifies children with cystic fibrosis at high risk of advanced liver disease. J Cyst Fibros 2023; 22:745-755. [PMID: 37032248 PMCID: PMC10523874 DOI: 10.1016/j.jcf.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND This study examines whether heterogeneous (HTG) pattern on liver ultrasound (US) identifies children at risk for advanced cystic fibrosis liver disease (aCFLD). METHODS Prospective 6-year multicenter case-controlled cohort study. Children with pancreatic insufficient cystic fibrosis (CF) aged 3-12 years without known cirrhosis underwent screening US. Participants with HTG were matched (by age, Pseudomonas infection status and center) 1:2 with participants with normal (NL) US pattern. Clinical status and laboratory data were obtained annually and US bi-annually for 6 years. Primary endpoint was development of nodular (NOD) US pattern consistent with aCFLD. RESULTS 722 participants underwent screening US, with 65 HTG and 592 NL. Final cohort included 55 HTG and 116 NL with ≥ 1 follow-up US. ALT, AST, GGTP, FIB-4, GPR and APRI were higher, and platelets were lower in HTG compared to NL. HTG had a 9.5-fold increased incidence (95% confidence interval [CI]:3.4, 26.7, p<0.0001, 32.7% vs 3.4%) of NOD versus NL. HTG had a sensitivity of 82% and specificity of 75% for subsequent NOD. Negative predictive value of a NL US for subsequent NOD was 96%. Multivariate logistic prediction model that included baseline US, age, and log(GPR) improved the C-index to 0.90 compared to only baseline US (C-index 0.78). Based on survival analysis, 50% of HTG develop NOD after 8 years. CONCLUSIONS Research US finding of HTG identifies children with CF with a 30-50% risk for aCFLD. A score based on US pattern, age and GPR may refine the identification of individuals at high risk for aCFLD. CLINICAL TRIAL REGISTRATION Prospective Study of Ultrasound to Predict Hepatic Cirrhosis in CF: NCT 01,144,507 (observational study, no consort checklist).
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Affiliation(s)
- Marilyn J Siegel
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston TX, USA
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Wen Ye
- Department of Biostatistics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Shruti M Paranjape
- Division of Pediatric Pulmonology, John Hopkins School of Medicine, Baltimore, MD, USA
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Atlanta, GA, USA
| | - 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, USA
| | - Janis Stoll
- Division of Gastroenterology and Nutrition, Washington University School of Medicine, St Louis, MO, USA
| | - Prakash Masand
- Division of Radiology, Texas Children's Hospital, Houston, TX, USA
| | - Boaz Karmazyn
- Pediatric Radiology, Riley Hospital for Children, Indianapolis, IN, USA
| | - Roger Harned
- Division of Pediatric Radiology, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - 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, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, John Hopkins School of Medicine, Baltimore, MD, USA
| | - Adina Alazraki
- Department of Radiology, Emory University School of Medicine and Children's Healthcare of Atlanta, Egleston, Atlanta, GA, USA
| | - Sarah Jane Schwarzenberg
- Pediatric Gastroenterology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Alex J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center and Department of Radiology, University of Cincinnati College of Medicine Cincinnati, OH, USA
| | - Estella M Alonso
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Jennifer L Nicholas
- Department of Radiology, Case Western Reserve School of Medicine, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Nicole Green
- Division of Gastroenterology and Hepatology, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Randolph K Otto
- Department of Radiology, Seattle Children's Hospital, Seattle, WA, USA
| | - John C Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael R Narkewicz
- Children's Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Digestive Health Institute, University of Colorado School of Medicine, Aurora, CO, USA.
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13
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Squires JE, Miethke AG, Valencia CA, Hawthorne K, Henn L, Van Hove JL, Squires RH, Bove K, Horslen S, Kohli R, Molleston JP, Romero R, Alonso EM, Bezerra JA, Guthery SL, Hsu E, Karpen SJ, Loomes KM, Ng VL, Rosenthal P, Mysore K, Wang KS, Friederich MW, Magee JC, Sokol RJ. Clinical spectrum and genetic causes of mitochondrial hepatopathy phenotype in children. Hepatol Commun 2023; 7:e0139. [PMID: 37184518 PMCID: PMC10187840 DOI: 10.1097/hc9.0000000000000139] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 11/10/2022] [Accepted: 01/19/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Alterations in both mitochondrial DNA (mtDNA) and nuclear DNA genes affect mitochondria function, causing a range of liver-based conditions termed mitochondrial hepatopathies (MH), which are subcategorized as mtDNA depletion, RNA translation, mtDNA deletion, and enzymatic disorders. We aim to enhance the understanding of pathogenesis and natural history of MH. METHODS We analyzed data from patients with MH phenotypes to identify genetic causes, characterize the spectrum of clinical presentation, and determine outcomes. RESULTS Three enrollment phenotypes, that is, acute liver failure (ALF, n = 37), chronic liver disease (Chronic, n = 40), and post-liver transplant (n = 9), were analyzed. Patients with ALF were younger [median 0.8 y (range, 0.0, 9.4) vs 3.4 y (0.2, 18.6), p < 0.001] with fewer neurodevelopmental delays (40.0% vs 81.3%, p < 0.001) versus Chronic. Comprehensive testing was performed more often in Chronic than ALF (90.0% vs 43.2%); however, etiology was identified more often in ALF (81.3% vs 61.1%) with mtDNA depletion being most common (ALF: 77% vs Chronic: 41%). Of the sequenced cohort (n = 60), 63% had an identified mitochondrial disorder. Cluster analysis identified a subset without an underlying genetic etiology, despite comprehensive testing. Liver transplant-free survival was 40% at 2 years (ALF vs Chronic, 16% vs 65%, p < 0.001). Eighteen (21%) underwent transplantation. With 33 patient-years of follow-up after the transplant, 3 deaths were reported. CONCLUSIONS Differences between ALF and Chronic MH phenotypes included age at diagnosis, systemic involvement, transplant-free survival, and genetic etiology, underscoring the need for ultra-rapid sequencing in the appropriate clinical setting. Cluster analysis revealed a group meeting enrollment criteria but without an identified genetic or enzymatic diagnosis, highlighting the need to identify other etiologies.
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Affiliation(s)
- James E. Squires
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - C. Alexander Valencia
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Interpath Laboratory, Pendleton, Oregon, USA
| | - Kieran Hawthorne
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Lisa Henn
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Johan L.K. Van Hove
- University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Robert H. Squires
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kevin Bove
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Simon Horslen
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rohit Kohli
- Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Jean P. Molleston
- Indiana University-Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Rene Romero
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Estella M. Alonso
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Jorge A. Bezerra
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Stephen L. Guthery
- University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City, Utah, USA
| | - Evelyn Hsu
- University of Washington School of Medicine and Seattle Children’s Hospital, Seattle, Washington, USA
| | - Saul J. Karpen
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kathleen M. Loomes
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Vicky L. Ng
- Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - Krupa Mysore
- Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kasper S. Wang
- Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Marisa W. Friederich
- University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - John C. Magee
- University of Michigan Hospitals and Health Centers, Ann Arbor, Michigan, USA
| | - Ronald J. Sokol
- University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, Colorado, USA
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Newton KP, Wilson LA, Crimmins NA, Fishbein MH, Molleston JP, Xanthakos SA, Behling C, Schwimmer JB. Incidence of Type 2 Diabetes in Children With Nonalcoholic Fatty Liver Disease. Clin Gastroenterol Hepatol 2023; 21:1261-1270. [PMID: 35709934 PMCID: PMC10151072 DOI: 10.1016/j.cgh.2022.05.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 12/15/2021] [Revised: 05/25/2022] [Accepted: 05/31/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Type 2 diabetes (T2D) is a growing problem in children. Children with NAFLD are at potentially high risk for developing T2D; however, the incidence of T2D in this population is unknown. This study aimed to determine the incidence of T2D in children with NAFLD and identify associated risk factors. METHODS Children with NAFLD enrolled in the Nonalcoholic Steatohepatitis Clinical Research Network were followed longitudinally. Incidence of T2D was determined by using clinical history and fasting laboratory values. Cumulative incidence curves were developed for time to T2D. A Cox regression multivariable model was constructed using best subsets Akaike's Information Criteria selection. RESULTS This study included 892 children with NAFLD and with a mean age of 12.8 years (2.7) followed for 3.8 years (2.3) with a total 3234 person-years at risk. The incidence rate of T2D was 3000 new cases per 100,000 person-years at risk. At baseline, 63 children had T2D, and during follow-up, an additional 97 children developed incident T2D, resulting in a period prevalence of 16.8%. Incident T2D was significantly higher in females versus males (hazard ratio [HR], 1.8 [1.0-2.8]), associated with BMI z-score (HR, 1.8 [1.0-3.0]), and more severe liver histology including steatosis grade (HR, 1.3 [1.0-1.7]), and fibrosis stage (HR, 1.3 [1.0-1.5]). CONCLUSIONS Children with NAFLD are at high risk for existing and incident T2D. In addition to known risk factors for T2D (female and BMI z-score), severity of liver histology at the time of NAFLD diagnosis was independently associated with T2D development. Targeted strategies to prevent T2D in children with NAFLD are needed.
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Affiliation(s)
- Kimberly P Newton
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California; Department of Gastroenterology, Rady Children's Hospital, San Diego, California
| | - Laura A Wilson
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Department of Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | - Nancy A Crimmins
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Mark H Fishbein
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jean P Molleston
- Department of Pediatrics, Riley Children's Hospital, Indianapolis, Indiana
| | - Stavra A Xanthakos
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Cynthia Behling
- Department of Pathology, Sharp Medical Center, San Diego, California
| | - Jeffrey B Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California; Department of Gastroenterology, Rady Children's Hospital, San Diego, California.
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15
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Harpavat S, Hawthorne K, Setchell KDR, Rivas MN, Henn L, Beil CA, Karpen SJ, Ng VL, Alonso EM, Bezerra JA, Guthery SL, Horslen S, Loomes KM, McKiernan P, Magee JC, Merion RM, Molleston JP, Rosenthal P, Thompson RJ, Wang KS, Sokol RJ, Shneider BL. Serum bile acids as a prognostic biomarker in biliary atresia following Kasai portoenterostomy. Hepatology 2023; 77:862-873. [PMID: 36131538 PMCID: PMC9936974 DOI: 10.1002/hep.32800] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 04/12/2022] [Revised: 08/22/2022] [Accepted: 09/04/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND AIMS In biliary atresia, serum bilirubin is commonly used to predict outcomes after Kasai portoenterostomy (KP). Infants with persistently high levels invariably need liver transplant, but those achieving normalized levels have a less certain disease course. We hypothesized that serum bile acid levels could help predict outcomes in the latter group. APPROACH AND RESULTS Participants with biliary atresia from the Childhood Liver Disease Research Network were included if they had normalized bilirubin levels 6 months after KP and stored serum samples from the 6-month post-KP clinic visit ( n = 137). Bile acids were measured from the stored serum samples and used to divide participants into ≤40 μmol/L ( n = 43) or >40 μmol/L ( n = 94) groups. At 2 years of age, the ≤40 μmol/L compared with >40 μmol/L group had significantly lower total bilirubin, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyltransferase, bile acids, and spleen size, as well as significantly higher albumin and platelet counts. Furthermore, during 734 person-years of follow-up, those in the ≤40 μmol/L group were significantly less likely to develop splenomegaly, ascites, gastrointestinal bleeding, or clinically evident portal hypertension. The ≤40 μmol/L group had a 10-year cumulative incidence of liver transplant/death of 8.5% (95% CI: 1.1%-26.1%), compared with 42.9% (95% CI: 28.6%-56.4%) for the >40 μmol/L group ( p = 0.001). CONCLUSIONS Serum bile acid levels may be a useful prognostic biomarker for infants achieving normalized bilirubin levels after KP.
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Affiliation(s)
- Sanjiv Harpavat
- Division of Gastroenterology, Department of Pediatrics , Hepatology and Nutrition, Baylor College of Medicine and Texas Children's Hospital , Houston , Texas , USA
| | - Kieran Hawthorne
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Kenneth D R Setchell
- Division of Pathology and Laboratory Medicine , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - Monica Narvaez Rivas
- Division of Pathology and Laboratory Medicine , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - Lisa Henn
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Charlotte A Beil
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Saul J Karpen
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Emory University School of Medicine , Atlanta , Georgia , USA
| | - Vicky L Ng
- Division of Gastroenterology, Hepatology and Nutrition , Hospital for Sick Children and University of Toronto , Toronto , Ontario , Canada
| | - Estella M Alonso
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Ann and Robert H. Lurie Children's Hospital of Chicago , Chicago , Illinois , USA
| | - Jorge A Bezerra
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - Stephen L Guthery
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , University of Utah , Salt Lake City , Utah , USA
| | - Simon Horslen
- Division of Gastroenterology and Hepatology, Department of Pediatrics , University of Washington Medical Center and Seattle Children's , Seattle , Washington , USA.,Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh , Pittsburgh , Pennsylvania , USA
| | - Kathy M Loomes
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Perelman School of Medicine at the University of Pennsylvania and Children's Hospital of Philadelphia , Philadelphia , Pennsylvania , USA
| | - Patrick McKiernan
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh , Pittsburgh , Pennsylvania , USA
| | - John C Magee
- Department of Surgery, Section of Transplant Surgery , University of Michigan Medical School , Ann Arbor , Michigan , USA
| | - Robert M Merion
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Jean P Molleston
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Indiana University School of Medicine and Riley Hospital for Children , Indianapolis , Indiana , USA
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , University of California San Francisco , San Francisco , California , USA
| | | | - Kasper S Wang
- Division of Pediatric Surgery, Department of Surgery , Children's Hospital of Los Angeles, University of Southern California , Los Angeles , California , USA
| | - Ronald J Sokol
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition , University of Colorado School of Medicine and Children's Hospital Colorado , Aurora , Colorado , USA
| | - Benjamin L Shneider
- Division of Gastroenterology, Department of Pediatrics , Hepatology and Nutrition, Baylor College of Medicine and Texas Children's Hospital , Houston , Texas , USA
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16
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Leung DH, Devaraj S, Goodrich NP, Chen X, Rajapakshe D, Ye W, Andreev V, Minard CG, Guffey D, Molleston JP, Bass LM, Karpen SJ, Kamath BM, Wang KS, Sundaram SS, Rosenthal P, McKiernan P, Loomes KM, Jensen MK, Horslen SP, Bezerra JA, Magee JC, Merion RM, Sokol RJ, Shneider BL, Alonso E, Bass L, Kelly S, Riordan M, Melin-Aldana H, Bezerra J, Bove K, Heubi J, Miethke A, Tiao G, Denlinger J, Chapman E, Sokol R, Feldman A, Mack C, Narkewicz M, Suchy F, Sundaram SS, Van Hove J, Garcia B, Kauma M, Kocher K, Steinbeiss M, Lovell M, Loomes KM, Piccoli D, Rand E, Russo P, Spinner N, Erlichman J, Stalford S, Pakstis D, King S, Squires R, Sindhi R, Venkat V, Bukauskas K, McKiernan P, Haberstroh L, Squires J, Rosenthal P, Bull L, Curry J, Langlois C, Kim G, Teckman J, Kociela V, Nagy R, Patel S, Cerkoski J, Molleston JP, Bozic M, Subbarao G, Klipsch A, Sawyers C, Cummings O, Horslen SP, Murray K, Hsu E, Cooper K, Young M, Finn L, Kamath BM, Ng V, Quammie C, Putra J, Sharma D, Parmar A, Guthery S, Jensen K, Rutherford A, Lowichik A, Book L, Meyers R, Hall T, Wang KS, Michail S, Thomas D, Goodhue C, Kohli R, Wang L, Soufi N, Thomas D, Karpen S, Gupta N, Romero R, Vos MB, Tory R, Berauer JP, Abramowsky C, McFall J, Shneider BL, Harpavat S, Hertel P, Leung D, Tessier M, Schady D, Cavallo L, Olvera D, Banks C, Tsai C, Thompson R, Doo E, Hoofnagle J, Sherker A, Torrance R, Hall S, Magee J, Merion R, Spino C, Ye W. Serum biomarkers correlated with liver stiffness assessed in a multicenter study of pediatric cholestatic liver disease. Hepatology 2023; 77:530-545. [PMID: 36069569 PMCID: PMC10151059 DOI: 10.1002/hep.32777] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 02/10/2022] [Revised: 07/26/2022] [Accepted: 08/03/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIMS Detailed investigation of the biological pathways leading to hepatic fibrosis and identification of liver fibrosis biomarkers may facilitate early interventions for pediatric cholestasis. APPROACH AND RESULTS A targeted enzyme-linked immunosorbent assay-based panel of nine biomarkers (lysyl oxidase, tissue inhibitor matrix metalloproteinase (MMP) 1, connective tissue growth factor [CTGF], IL-8, endoglin, periostin, Mac-2-binding protein, MMP-3, and MMP-7) was examined in children with biliary atresia (BA; n = 187), alpha-1 antitrypsin deficiency (A1AT; n = 78), and Alagille syndrome (ALGS; n = 65) and correlated with liver stiffness (LSM) and biochemical measures of liver disease. Median age and LSM were 9 years and 9.5 kPa. After adjusting for covariates, there were positive correlations among LSM and endoglin ( p = 0.04) and IL-8 ( p < 0.001) and MMP-7 ( p < 0.001) in participants with BA. The best prediction model for LSM in BA using clinical and lab measurements had an R2 = 0.437; adding IL-8 and MMP-7 improved R2 to 0.523 and 0.526 (both p < 0.0001). In participants with A1AT, CTGF and LSM were negatively correlated ( p = 0.004); adding CTGF to an LSM prediction model improved R2 from 0.524 to 0.577 ( p = 0.0033). Biomarkers did not correlate with LSM in ALGS. A significant number of biomarker/lab correlations were found in participants with BA but not those with A1AT or ALGS. CONCLUSIONS Endoglin, IL-8, and MMP-7 significantly correlate with increased LSM in children with BA, whereas CTGF inversely correlates with LSM in participants with A1AT; these biomarkers appear to enhance prediction of LSM beyond clinical tests. Future disease-specific investigations of change in these biomarkers over time and as predictors of clinical outcomes will be important.
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Affiliation(s)
- Daniel H Leung
- Division of Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Department of Pediatrics , Baylor College of Medicine , Houston , Texas , USA
| | - Sridevi Devaraj
- Department of Pathology and Immunology , Texas Children's Hospital, Baylor College of Medicine , Houston , Texas , USA
| | - Nathan P Goodrich
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Xinpu Chen
- Department of Pathology and Immunology , Texas Children's Hospital, Baylor College of Medicine , Houston , Texas , USA
| | - Deepthi Rajapakshe
- Department of Pathology and Immunology , Texas Children's Hospital, Baylor College of Medicine , Houston , Texas , USA
| | - Wen Ye
- Department of Biostatistics , University of Michigan , Ann Arbor , Michigan , USA
| | - Victor Andreev
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Charles G Minard
- Institute for Clinical and Translational Research , Baylor College of Medicine , Houston , Texas , USA
| | - Danielle Guffey
- Institute for Clinical and Translational Research , Baylor College of Medicine , Houston , Texas , USA
| | - Jean P Molleston
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics , Riley Hospital for Children , Indiana University , Indianapolis , Indiana , USA
| | - Lee M Bass
- Department of Pediatrics , Ann & Robert H. Lurie Children's Hospital of Chicago , Northwestern University Feinberg School of Medicine , Chicago , Illinois , USA
| | - Saul J Karpen
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, Department of Pediatrics , Emory University School of Medicine , Atlanta , Georgia , USA
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition , Hospital for Sick Children, University of Toronto , Toronto , Ontario , Canada
| | - Kasper S Wang
- Department of Pediatric Surgery , Children's Hospital Los Angeles , Los Angeles , California , USA
| | - Shikha S Sundaram
- Pediatric Gastroenterology, Hepatology and Nutrition , Children's Hospital Colorado, University of Colorado School of Medicine , Aurora , Colorado , USA
| | - Philip Rosenthal
- Department of Pediatrics , University of California, San Francisco , San Francisco , California , USA
| | - Patrick McKiernan
- Pediatric Gastroenterology, Hepatology and Nutrition , Children's Hospital of Pittsburgh , Pittsburg , Pennsylvania , USA
| | - Kathleen M Loomes
- Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania , Philadelphia , Pennsylvania , USA
| | - M Kyle Jensen
- Pediatric Gastroenterology, Hepatology and Nutrition , University of Utah School of Medicine , Salt Lake City , Utah , USA
| | - Simon P Horslen
- Pediatric Gastroenterology, Hepatology and Nutrition , Seattle Children's Hospital, University of Washington School of Medicine , Seattle , Washington , USA
| | - Jorge A Bezerra
- Pediatric Gastroenterology, Hepatology and Nutrition , Cincinnati Children's Medical Center, University of Cincinnati School of Medicine , Cincinnati , Ohio , USA
| | - John C Magee
- University of Michigan Hospitals and Health Centers , Ann Arbor , Michigan , USA
| | - Robert M Merion
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Ronald J Sokol
- Pediatric Gastroenterology, Hepatology and Nutrition , Children's Hospital Colorado, University of Colorado School of Medicine , Aurora , Colorado , USA
| | - Benjamin L Shneider
- Division of Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Department of Pediatrics , Baylor College of Medicine , Houston , Texas , USA
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17
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Goyal NP, Rosenthal SB, Nasamran C, Behling CA, Angeles JE, Fishbein MH, Harlow KE, Jain AK, Molleston JP, Newton KP, Ugalde-Nicalo P, Xanthankos SA, Yates K, Schork NJ, Fisch KM, Schwimmer JB. Nonalcoholic fatty liver disease risk and histologic severity are associated with genetic polymorphisms in children. Hepatology 2023; 77:197-212. [PMID: 35560106 PMCID: PMC9653518 DOI: 10.1002/hep.32570] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 01/06/2022] [Revised: 05/09/2022] [Accepted: 05/09/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS NAFLD is the most common chronic liver disease in children. Large pediatric studies identifying single nucleotide polymorphisms (SNPs) associated with risk and histologic severity of NAFLD are limited. Study aims included investigating SNPs associated with risk for NAFLD using family trios and association of candidate alleles with histologic severity. APPROACH AND RESULTS Children with biopsy-confirmed NAFLD were enrolled from the NASH Clinical Research Network. The Expert Pathology Committee reviewed liver histology. Genotyping was conducted with allele-specific primers for 60 candidate SNPs. Parents were enrolled for trio analysis. To assess risk for NAFLD, the transmission disequilibrium test was conducted in trios. Among cases, regression analysis assessed associations with histologic severity. A total of 822 children with NAFLD had mean age 13.2 years (SD 2.7) and mean ALT 101 U/L (SD 90). PNPLA3 (rs738409) demonstrated the strongest risk ( p = 2.24 × 10 -14 ) for NAFLD. Among children with NAFLD, stratifying by PNPLA3 s738409 genotype, the variant genotype associated with steatosis ( p = 0.005), lobular ( p = 0.03) and portal inflammation ( p = 0.002). Steatosis grade associated with TM6SF2 ( p = 0.0009), GCKR ( p = 0.0032), PNPLA3 rs738409 ( p = 0.0053), and MTTP ( p = 0.0051). Fibrosis stage associated with PARVB rs6006473 ( p = 0.0001), NR1I2 ( p = 0.0021), ADIPOR2 ( p = 0.0038), and OXTR ( p = 0.0065). PNPLA3 rs738409 ( p = 0.0002) associated with borderline zone 1 NASH. CONCLUSIONS This study demonstrated disease-associated SNPs in children with NAFLD. In particular, rs6006473 was highly associated with severity of fibrosis. These hypothesis-generating results support future mechanistic studies of development of adverse outcomes such as fibrosis and generation of therapeutic targets for NAFLD in children.
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Affiliation(s)
- Nidhi P. Goyal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California, USA
- Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, California, USA
| | - Sara B. Rosenthal
- Center for Computational Biology and Bioinformatics, University of California, San Diego, La Jolla, California, USA
| | - Chanod Nasamran
- Center for Computational Biology and Bioinformatics, University of California, San Diego, La Jolla, California, USA
| | - Cynthia A. Behling
- Department of Pathology, Sharp Memorial Hospital; Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego, California, USA
| | - Jorge E. Angeles
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California, USA
| | - Mark H. Fishbein
- Department of Pediatrics, Feinberg Medical School of Northwestern University, Chicago, Illinois, USA
| | - Kathryn E. Harlow
- Riley Hospital for Children At Indiana University Health, Indianapolis, Indiana, USA
| | - Ajay K. Jain
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, St. Louis University, St. Louis, Missouri, USA
| | - Jean P. Molleston
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Kimberly P. Newton
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California, USA
- Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, California, USA
| | - Patricia Ugalde-Nicalo
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California, USA
| | - Stavra A. Xanthankos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Katherine Yates
- Department of Epidemiology and Biostatistics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nicholas J. Schork
- The Translational Genomics Research Institute (TGen), Phoenix, Arizona, USA
- Department of Molecular and Cell Biology, The City of Hope National Medical Center, Duarte, California, USA
| | - Kathleen M. Fisch
- Center for Computational Biology and Bioinformatics, University of California, San Diego, La Jolla, California, USA
| | - Jeffrey B. Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California, USA
- Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, California, USA
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18
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Schwarzenberg SJ, Palermo JJ, Ye W, Huang S, Magee JC, Alazraki A, Jay Freeman A, Harned R, Karmazyn B, Karnsakul W, Leung DH, Ling SC, Masand P, Molleston JP, Murray KF, Navarro OM, Nicholas JL, Otto RK, Paranjape SM, Siegel MJ, Stoll J, Towbin AJ, Narkewicz MR, Alonso EM. Health-related Quality of Life in a Prospective Study of Ultrasound to Detect Cystic Fibrosis-related Liver Disease in Children. J Pediatr Gastroenterol Nutr 2022; 75:635-642. [PMID: 36070552 PMCID: PMC9624376 DOI: 10.1097/mpg.0000000000003605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Cystic fibrosis liver disease (CFLD) begins early in life. Symptoms may be vague, mild, or nonexistent. Progressive liver injury may be associated with decrements in patient health before liver disease is clinically apparent. We examined Health-Related Quality of Life (HRQOL) in children enrolled in a multi-center study of CFLD to determine the impact of early CFLD on general and disease-specific QOL. METHODS Ultrasound (US) patterns of normal (NL), heterogeneous (HTG), homogeneous (HMG), or nodular (NOD) were assigned in a prospective manner to predict those at risk for advanced CFLD. Parents were informed of results. We assessed parent/child-reported (age ≥5 years) HRQOL by PedsQL 4.0 Generic Core and CF Questionnaire-revised (CFQ-R) prior to US and annually. HRQOL scores were compared by US pattern at baseline (prior to US), between baseline and 1 year and at 5 years. Multivariate analysis of variance (MANOVA) with Hotelling-Lawley trace tested for differences among US groups. RESULTS Prior to US, among 515 participants and their parents there was no evidence that HTG or NOD US was associated with reduced PedsQL/CFQ-R at baseline. Parents of NOD reported no change in PedsQL/CFQ-R over the next year. Child-report PedsQL/CFQ-R (95 NL, 20 NOD) showed improvement between baseline and year 5 for many scales, including Physical Function. Parents of HMG children reported improved CFQ-R scores related to weight. CONCLUSIONS Early undiagnosed or pre-symptomatic liver disease had no impact on generic or disease-specific HRQoL, and HRQoL was remarkably stable in children with CF regardless of liver involvement.
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Affiliation(s)
- Sarah Jane Schwarzenberg
- Pediatric Gastroenterology, Hepatology and Nutrition, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN
| | - 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
| | - Wen Ye
- Department of Biostatistics, University of Michigan Medical School, Ann Arbor, MI
| | - Suiyuan Huang
- Department of Biostatistics, University of Michigan Medical School, Ann Arbor, MI
| | - John C. Magee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Adina Alazraki
- Department of Radiology, Emory University School of Medicine and Children’s Healthcare of Atlanta, Egleston, Atlanta, GA
| | - A. Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, and Children’s Healthcare of Atlanta, Atlanta, GA
| | - Roger Harned
- Division of Pediatric Radiology, Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | - Boaz Karmazyn
- Pediatric Radiology, Riley Hospital for Children, Indianapolis, IN
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, John Hopkins School of Medicine, Baltimore, MD
| | - Daniel H. Leung
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children’s Hospital, Houston TX
| | - Simon C. Ling
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Prakash Masand
- Division Radiology, Texas Children’s Hospital, Houston TX
| | - Jean P. Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Karen F. Murray
- Pediatric Institute, Cleveland Clinic and Cleveland Clinic Children’s, Cleveland, OH
| | - Oscar M. Navarro
- Department of Medical Imaging, University of Toronto and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jennifer L. Nicholas
- Division of Pediatric Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine
| | - Randolph K. Otto
- Department of Radiology, Seattle Children’s Hospital, Seattle, WA
| | - Shruti M. Paranjape
- Division of Pediatric Pulmonology, John Hopkins School of Medicine, Baltimore, MD
| | - Marilyn J. Siegel
- Division of Pediatric Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine
| | - Janis Stoll
- Division of Gastroenterology and Nutrition, Washington University School of Medicine, St Louis, MO
| | - Alexander J. Towbin
- Department of Radiology, Cincinnati Children’s Hospital Medical Center and Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - 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
| | - Estella M. Alonso
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children’s Hospital, Chicago, IL
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Bass LM, Ye W, Hawthorne K, Leung DH, Murray KF, Molleston JP, Romero R, Karpen S, Rosenthal P, Loomes KM, Wang KS, Squires RH, Miethke A, Ng VL, Horslen S, Kyle Jensen M, Sokol RJ, Magee JC, Shneider BL, Bass L, Kelly S, Riordan M, Melin‐Aldana H, Bezerra J, Bove K, Heubi J, Miethke A, Tiao G, Denlinger J, Chapman E, Sokol R, Feldman A, Mack C, Narkewicz M, Suchy F, Sundaram S, Van Hove J, Garcia B, Kauma M, Kocher K, Steinbeiss M, Lovell M, Loomes K, Piccoli D, Rand E, Russo P, Spinner N, Erlichman J, Stalford S, Pakstis D, King S, Squires R, Sindhi R, Venkat V, Bukauskas K, McKiernan P, Haberstroh L, Squires J, Rosenthal P, Bull L, Curry J, Langlois C, Kim G, Teckman J, Kociela V, Nagy R, Patel S, Cerkoski J, Molleston JP, Bozic M, Subbarao G, Klipsch A, Sawyers C, Cummings O, Horslen S, Murray K, Hsu E, Cooper K, Young M, Finn L, Kamath B, Ng V, Quammie C, Putra J, Sharma D, Parmar A, Guthery S, Jensen K, Rutherford A, Lowichik A, Book L, Meyers R, Hall T, Wang K, Michail S, Thomas D, Goodhue C, Kohli R, Wang L, Soufi N, Thomas D, Karpen S, Gupta N, Romero R, Vos MB, Tory R, Berauer J, Abramowsky C, McFall J, Shneider B, Harpavat S, Hertel P, Leung D, Tessier M, Schady D, Cavallo L, Olvera D, Banks C, Tsai C, Thompson R, Doo E, Hoofnagle J, Sherker A, Torrance R, Hall S, Magee J, Merion R, Spino C, Ye W. Risk of variceal hemorrhage and pretransplant mortality in children with biliary atresia. Hepatology 2022; 76:712-726. [PMID: 35271743 PMCID: PMC9378352 DOI: 10.1002/hep.32451] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 06/11/2020] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The natural history of gastroesophageal variceal hemorrhage (VH) in biliary atresia (BA) is not well characterized. We analyzed risk factors, incidence, and outcomes of VH in a longitudinal multicenter study. APPROACH AND RESULTS Participants enrolled in either an incident (Prospective Database of Infants with Cholestasis [PROBE]) or prevalent (Biliary Atresia Study of Infants and Children [BASIC]) cohort of BA were included. Variceal hemorrhage (VH) was defined based on gastrointestinal bleeding in the presence of varices accompanied by endoscopic or nontransplant surgical intervention. Cumulative incidence of VH and transplant-free survival was compared based on features of portal hypertension (e.g., splenomegaly, thrombocytopenia) and clinical parameters at baseline in each cohort (PROBE: 1.5 to 4.5 months after hepatoportoenterostomy [HPE]; BASIC: at enrollment > 3 years of age). Analyses were conducted on 869 children with BA enrolled between June 2004 and December 2020 (521 in PROBE [262 (51%) with a functioning HPE] and 348 in BASIC). The overall incidence of first observed VH at 5 years was 9.4% (95% CI: 7.0-12.4) in PROBE and 8.0% (5.2-11.5) in BASIC. Features of portal hypertension, platelet count, total bilirubin, aspartate aminotransferase (AST), albumin, and AST-to-platelet ratio index at baseline were associated with an increased risk of subsequent VH in both cohorts. Transplant-free survival at 5 years was 45.1% (40.5-49.6) in PROBE and 79.2% (74.1-83.4) in BASIC. Two (2.5%) of 80 participants who had VH died, whereas 10 (12.5%) underwent transplant within 6 weeks of VH. CONCLUSIONS The low risk of VH and associated mortality in children with BA needs to be considered in decisions related to screening for varices and primary prophylaxis of VH.
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Affiliation(s)
- Lee M Bass
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Wen Ye
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Kieran Hawthorne
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Karen F Murray
- Division of Gastroenterology, Department of Pediatrics, Hepatology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, Washington State, USA
| | - Jean P Molleston
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, USA
| | - Rene Romero
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Saul Karpen
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Philip Rosenthal
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kasper S Wang
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Robert H Squires
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh, School of Medicine and Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alexander Miethke
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Vicky L Ng
- Division of GI, Hepatology and Nutrition, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Simon Horslen
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington State, USA
| | - M Kyle Jensen
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Ronald J Sokol
- Department of Pediatrics-Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - John C Magee
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Benjamin L Shneider
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
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20
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Leung DH, Ye W, Schwarzenberg SJ, Freeman AJ, Palermo JJ, Weymann A, Alonso EM, Karnsakul WW, Murray KF, Stoll JM, Huang S, Karmazyn B, Masand P, Magee JC, Alazraki AL, Towbin AJ, Nicholas JL, Green N, Otto RK, Siegel MJ, Ling SC, Navarro OM, Harned RK, Narkewicz MR, Molleston JP. Long-term follow-up and liver outcomes in children with cystic fibrosis and nodular liver on ultrasound in a multi-center study. J Cyst Fibros 2022; 22:248-255. [PMID: 35985930 DOI: 10.1016/j.jcf.2022.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 03/10/2022] [Revised: 06/30/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Nodular liver (NOD) in cystic fibrosis (CF) suggests advanced CF liver disease (aCFLD); little is known about progression of liver disease (LD) after detection of sonographic NOD. METHODS Clinical, laboratory, and ultrasound (US) data from Prediction by Ultrasound of the Risk of Hepatic Cirrhosis in CFLD Study participants with NOD at screening or follow-up were compared with normal (NL). Linear mixed effects models were used for risk factors for LD progression and Kaplan-Meier estimator for time-to-event. RESULTS 54 children with NOD (22 screening, 32 follow-up) and 112 NL were evaluated. Baseline (BL) and trajectory of forced expiratory volume, forced vital capacity, height/BMI z-scores were similar in NOD vs NL. Platelets were lower in NOD at BL (250 vs 331×103/microL; p < 0.001) and decreased by 8600/year vs 2500 in NL. Mean AST to Platelet Ratio Index (1.1 vs 0.4; p < 0.001), Fibrosis-4 Index (0.4 vs 0.2, p < 0.001), and spleen size z-score (SSZ) [1.5 vs 0.02; p < 0.001] were higher in NOD at BL; SSZ increased by 0.5 unit/year in NOD vs 0.1 unit/year in NL. Median liver stiffness (LSM) by transient elastography was higher in NOD (8.2 kPa, IQR 6-11.8) vs NL (5.3, 4.2-7, p < 0.0001). Over 6.3 years follow-up (1.3-10.3), 6 NOD had esophageal varices (cumulative incidence in 10 years: 20%; 95% CI: 0.0%, 40.0%), 2 had variceal bleeding, and 2 underwent liver transplantation; none had ascites or hepatic encephalopathy. No NL experienced liver-related events. CONCLUSIONS NOD developed clinically evident portal hypertension faster than NL without worse growth or lung disease.
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Key Words
- ALT, alanine aminotransferase
- APRI, aspartate aminotransferase to platelet ratio index
- AST, aminotransferase
- CAP, continuous attenuation parameter
- CFRD, cystic-fibrosis-related diabetes
- CFTR, cystic fibrosis transmembrane regulator
- Cirrhosis
- Cystic fibrosis liver disease
- FEV1, forced expiratory volume in one second
- FIB4, fibrosis index based on four factors
- FVC, forced vital capacity
- GGT, gamma-glutamyl transferase
- IGT, impaired glucose tolerance
- INR, international normalized ratio
- LSM, liver stiffness measurement
- NL, normal
- NOD, nodular
- PELD, pediatric end-stage liver disease
- PUSH, prediction by ultrasound of the risk of hepatic cirrhosis
- US, ultrasound
- Ultrasound
- VCTE, vibration controlled transient elastography
- WBC, white blood cell count
- abbreviations: CF, cystic fibrosis
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Affiliation(s)
- Daniel H Leung
- Department of Pediatrics, Baylor College of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, 6621 Fannin St, CCC 1010.00, Houston, TX 77030, USA
| | - Wen Ye
- Department of Biostatistics, University of Michigan, 1420 Washington Heights, M4073 SPH II, Ann Arbor, MI 48109, USA
| | - Sarah J Schwarzenberg
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Minnesota, 2450 Riverside Save S AO-201, Minneapolis, MN 55454, USA
| | - A Jay Freeman
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University, 2015 Uppergate Drive, NE, Atlanta, GA 30322, USA
| | - Joseph J Palermo
- Department of Pediatrics, Division of Gastroenterology, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 2010, Cincinnati, OH 45229, USA
| | - Alexander Weymann
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA
| | - Estella M Alonso
- Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, Northwestern University Feinberg School of Medicine, 225 E. Chicago Avenue, Box 57, Chicago, IL 60611, USA
| | - Wikrom W Karnsakul
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, 600 N Wolfe Street, CMSC-2, Baltimore, MD 21287, USA
| | - Karen F Murray
- Pediatric Institute and Cleveland Clinic Children's, Cleveland Clinic, 8950 Euclid Avenue, R3, Cleveland, OH 44195, USA
| | - Janis M Stoll
- Department of Pediatrics, Division of Gastroenterology, Pediatric Hepatology and Nutrition, Washington University School of Medicine in St. Louis, One Children's Place, Suite 8116, St. Louis, MO 63110, USA
| | - Suiyuan Huang
- Department of Biostatistics, University of Michigan, 1420 Washington Heights, M4073 SPH II, Ann Arbor, MI 48109, USA
| | - Boaz Karmazyn
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N. University Blvd, Rm 0663, Indianapolis, IN 46202, USA
| | - Prakash Masand
- Department of Pediatrics, Baylor College of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, 6621 Fannin St, CCC 1010.00, Houston, TX 77030, USA
| | - John C Magee
- Department of Surgery, University of Michigan School of Medicine, 1500 E Medical Center Drive, UH South Rm 6689, Ann Arbor, MI 48109, USA
| | - Adina L Alazraki
- Department of Radiology, Children's Healthcare of Atlanta, Emory University, 1405 Clifton Rd NE, Atlanta, GA 30322, USA
| | - Alexander J Towbin
- Department of Radiology, University of Cincinnati College of Medicine, 234 Goodman Street, PO Box 670761, Cincinnati, OH 45267, USA
| | - Jennifer L Nicholas
- Department of Radiology, Division of Pediatric Imaging, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Nicole Green
- Department of Pediatrics, Division of Gastroenterology and Hepatology, Seattle Children's Hospital, 4800 Sand Point Way NE, PO Box 5371, Seattle, WA 98105, USA
| | - Randolph K Otto
- Department of Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, MA.7.220, Seattle, WA 98105, USA
| | - Marilyn J Siegel
- Edward Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Blvd, St. Louis, MO 63110, USA
| | - Simon C Ling
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, University of Toronto, 555 University Ave ON, Toronto, M5G 1X8, Canada
| | - Oscar M Navarro
- Department of Diagnostic Imaging, Division of Pediatric Imaging, University of Toronto, 263 McCaul St 4th floor, Toronto, ON M5T 1W7, Canada
| | - Roger K Harned
- Department of Radiology-Diagnostics, University of Colorado School of Medicine, 13123 East 16th Avenue, B125, Aurora, CO 80045, USA
| | - Michael R Narkewicz
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, B290, Aurora, CO 80045, USA
| | - Jean P Molleston
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children at IU Health, Indiana University School of Medicine, 705 Riley Hospital Drive, ROC 4210, Indianapolis, IN 46202, USA.
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21
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Vos MB, Van Natta ML, Blondet NM, Dasarathy S, Fishbein M, Hertel P, Jain AK, Karpen SJ, Lavine JE, Mohammad S, Miriel LA, Molleston JP, Mouzaki M, Sanyal A, Sharkey EP, Schwimmer JB, Tonascia J, Wilson LA, Xanthakos SA. Randomized placebo-controlled trial of losartan for pediatric NAFLD. Hepatology 2022; 76:429-444. [PMID: 35133671 PMCID: PMC9288975 DOI: 10.1002/hep.32403] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 04/24/2021] [Revised: 11/18/2021] [Accepted: 12/04/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIMS To date, no pharmacotherapy exists for pediatric NAFLD. Losartan, an angiotensin II receptor blocker, has been proposed as a treatment due to its antifibrotic effects. APPROACH AND RESULTS The Nonalcoholic Steatohepatitis Clinical Research Network conducted a multicenter, double-masked, placebo-controlled, randomized clinical trial in children with histologically confirmed NAFLD at 10 sites (September 2018 to April 2020). Inclusion criteria were age 8-17 years, histologic NAFLD activity score ≥ 3, and serum alanine aminotransferase (ALT) ≥ 50 U/l. Children received 100 mg of losartan or placebo orally once daily for 24 weeks. The primary outcome was change in ALT levels from baseline to 24 weeks, and the preset sample size was n = 110. Treatment effects were assessed using linear regression of change in treatment group adjusted for baseline value. Eighty-three participants (81% male, 80% Hispanic) were randomized to losartan (n = 43) or placebo (n = 40). During an enrollment pause, necessitated by the 2019 coronavirus pandemic, an unplanned interim analysis showed low probability (7%) of significant group difference. The Data and Safety Monitoring Board recommended early study termination. Baseline characteristics were similar between groups. The 24-week change in ALT did not differ significantly between losartan versus placebo groups (adjusted mean difference: 1.1 U/l; 95% CI = -30.6, 32.7; p = 0.95), although alkaline phosphatase decreased significantly in the losartan group (adjusted mean difference: -23.4 U/l; 95% CI = -41.5, -5.3; p = 0.01). Systolic blood pressure decreased in the losartan group but increased in placebo (adjusted mean difference: -7.5 mm Hg; 95% CI = -12.2, -2.8; p = 0.002). Compliance by pill counts and numbers and types of adverse events did not differ by group. CONCLUSIONS Losartan did not significantly reduce ALT in children with NAFLD when compared with placebo.
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Affiliation(s)
- Miriam B Vos
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Mark L Van Natta
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Niviann M Blondet
- Division of Pediatric Gastroenterology and Hepatology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Srinivasan Dasarathy
- Division of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark Fishbein
- Department of Pediatrics, Feinberg Medical School of Northwestern University, Chicago, Illinois, USA
| | - Paula Hertel
- Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Ajay K Jain
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, St. Louis University, St. Louis, Missouri, USA
| | - Saul J Karpen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Joel E Lavine
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Saeed Mohammad
- Department of Pediatrics, Feinberg Medical School of Northwestern University, Chicago, Illinois, USA
| | - Laura A Miriel
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jean P Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Arun Sanyal
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Emily P Sharkey
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jeffrey B Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California, USA
| | - James Tonascia
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Laura A Wilson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Stavra A Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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22
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Shneider BL, Kamath BM, Magee JC, Goodrich NP, Loomes KM, Ye W, Spino C, Alonso EM, Molleston JP, Bezerra JA, Wang KS, Karpen SJ, Horslen SP, Guthery SL, Rosenthal P, Squires RH, Sokol RJ. Use of funded multicenter prospective longitudinal databases to inform clinical trials in rare diseases-Examination of cholestatic liver disease in Alagille syndrome. Hepatol Commun 2022; 6:1910-1921. [PMID: 35506349 PMCID: PMC9315119 DOI: 10.1002/hep4.1970] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/18/2022] [Accepted: 03/19/2022] [Indexed: 01/28/2023] Open
Abstract
The conduct of long-term conventional randomized clinical trials in rare diseases is very difficult, making evidenced-based drug development problematic. As a result, real-world data/evidence are being used more frequently to assess new therapeutic approaches in orphan diseases. In this investigation, inclusion and exclusion criteria from a published trial of maralixibat in Alagille syndrome (ALGS, ITCH NCT02057692) were applied to a prospective longitudinal cohort of children with cholestasis (LOGIC NCT00571272) to derive contextual comparator data for evolving clinical trials of intestinal bile acid transport inhibitors in ALGS. A natural history/clinical care cohort of 59 participants who met adapted inclusion and exclusion criteria of ITCH was identified from 252 LOGIC participants with ALGS with their native liver. Frequency weighting was used to match the age distribution of ITCH and yielded a cohort (Alagille Syndrome Natural History [ALGS NH]) that was very similar to the baseline status of ITCH participants. During a 2-year prospective follow-up there was a significant reduction in pruritus in the weighted ALGS NH cohort as assessed by the clinician scratch score (-1.43 [0.28] -1.99, -0.87; mean [SEM] 95% confidence interval). During the same time period, the total bilirubin, albumin, and alanine aminotransferase levels were unchanged, whereas platelet count dropped significantly (-65.2 [16.2] -98.3, -32.1). Weighted survival with native liver was 91% at 2 years in the ALGS NH. These investigations provide valuable real-world data that can serve as contextual comparators to current clinical trials, especially those without control populations, and highlight the value and importance of funded multicenter, prospective, natural history studies.
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Affiliation(s)
| | | | | | | | - Kathleen M. Loomes
- Division of Gastroenterology, Hepatology and NutritionThe Children’s Hospital of Philadelphia and Department of PediatricsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Wen Ye
- University of MichiganAnn ArborMichiganUSA
| | | | - Estella M. Alonso
- Division of Gastroenterology, Hepatology, and NutritionAnn & Robert H. Lurie Children’s Hospital of ChicagoNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Jean P. Molleston
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsRiley Hospital for Children, Indiana UniversityIndianapolisIndianaUSA
| | | | | | - Saul J. Karpen
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsChildren’s Healthcare of Atlanta and Emory University School of MedicineAtlantaGeorgiaUSA
| | - Simon P. Horslen
- Department of PediatricsSeattle Children’s HospitalUniversity of Washington School of MedicineSeattleWAUSA
| | - Stephen L. Guthery
- Division of Gastroenterology, Hepatology and NutritionDepartment of PediatricsUniversity of Utah, and Intermountain Primary Children’s HospitalSalt Lake CityUtahUSA
| | - Philip Rosenthal
- Department of PediatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Robert H. Squires
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsUniversity of PittsburghSchool of Medicine and Children’s Hospital of Pittsburgh of University of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Ronald J. Sokol
- Department of Pediatrics‐Gastroenterology, Hepatology and NutritionUniversity of Colorado School of Medicine and Children’s Hospital ColoradoAuroraColoradoUSA
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23
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Shneider BL, Spino CA, Kamath BM, Magee JC, Ignacio RV, Huang S, Horslen SP, Molleston JP, Miethke AG, Kohli R, Leung DH, Jensen MK, Loomes KM, Karpen SJ, Mack C, Rosenthal P, Squires RH, Baker A, Rajwal S, Kelly D, Sokol RJ, Thompson RJ. Impact of long-term administration of maralixibat on children with cholestasis secondary to Alagille syndrome. Hepatol Commun 2022; 6:1922-1933. [PMID: 35672955 PMCID: PMC9315125 DOI: 10.1002/hep4.1992] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 12/23/2021] [Accepted: 04/03/2022] [Indexed: 11/10/2022] Open
Abstract
There is growing interest in, but limited data about, intestinal bile acid transport inhibitors as treatment for cholestatic liver disease. The current analyses combine two similar randomized placebo-controlled trials with subsequent extension phases investigating the impact of maralixibat in children with severe cholestasis secondary to Alagille Syndrome (n = 57). The primary outcomes were measures of pruritus (ItchRO[Obs]) and clinician scratch scale (CSS), both increasing in severity from 0 to 4) and quality of life (QoL) (Parent PedsQL and Multidimensional Fatigue Scale module [MFS] scaled 0-100 with increased QoL) at week 48 of the extension phase relative to the baseline of the placebo-controlled trials (week 13). Secondary assessments included other clinical and biochemical parameters assessed in participants at week 72 or end of treatment (after week 48). At week 48, statistically and clinically significant least square mean (95% CI) improvements in pruritus and QoL were observed (ItchRO[Obs] -1.59 [-1.81, -1.36], CSS -1.36 [-1.67, -1.05], PedsQL +10.17 [4.48, 15.86], and multidimension fatigue [MFS] +13.97 [7.85, 20.08]). At week 48, serum bile acids, platelet count, and cholesterol decreased, whereas alanine aminotransferase (ALT) increased and total bilirubin (TB) and albumin were stable. Changes were durable at week 72 and end of treatment. There were no deaths; 2 participants underwent liver transplantation. Study drug was discontinued in 9 participants after treatment-emergent adverse events, 6 of which were events of increased ALT or TB. Conclusion: Maralixibat administration was associated with marked improvement in pruritus and QoL. Interpretation of these findings is complicated by the complex natural history of severe cholestasis in Alagille syndrome.
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Affiliation(s)
- Benjamin L Shneider
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsBaylor College of Medicine and Texas Children's HospitalHoustonTexasUSA
| | | | | | | | | | | | - Simon P Horslen
- Department of PediatricsSeattle Children's HospitalUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Jean P Molleston
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsRiley Hospital for ChildrenIndiana UniversityIndianapolisIndianaUSA
| | - Alexander G Miethke
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsUniversity of CincinnatiCincinnatiOhioUSA
| | - Rohit Kohli
- Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA.,Liver Transplant ProgramChildren's Hospital-Los AngelesLos AngelesCaliforniaUSA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsBaylor College of Medicine and Texas Children's HospitalHoustonTexasUSA
| | - M Kyle Jensen
- Department of PediatricsUniversity of UtahSalt Lake CityUtahUSA
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology, and NutritionThe Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Saul J Karpen
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsChildren's Healthcare of Atlanta and Emory University School of MedicineAtlantaGeorgiaUSA
| | - Cara Mack
- Department of Pediatrics-Gastroenterology, Hepatology, and NutritionUniversity of Colorado School of Medicine and Children's Hospital ColoradoAuroraColoradoUSA
| | - Philip Rosenthal
- Department of PediatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Robert H Squires
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsUniversity of Pittsburgh, School of Medicine and Children's Hospital of Pittsburgh of University of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Alastair Baker
- Department of Child HealthThe Pediatric Liver CenterKing's College HospitalLondonUK
| | | | - Deirdre Kelly
- Liver UnitBirmingham Women's & Children's HospitalBirminghamUK
| | - Ronald J Sokol
- Department of PediatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Richard J Thompson
- Department of Child HealthThe Pediatric Liver CenterKing's College HospitalLondonUK
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24
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Leung DH, Sorensen LG, Ye W, Hawthorne K, Ng VL, Loomes KM, Fredericks EM, Alonso EM, Heubi JE, Horslen SP, Karpen SJ, Molleston JP, Rosenthal P, Sokol RJ, Squires RH, Wang KS, Kamath BM, Magee JC. Neurodevelopmental Outcomes in Children With Inherited Liver Disease and Native Liver. J Pediatr Gastroenterol Nutr 2022; 74:96-103. [PMID: 34694263 PMCID: PMC8673857 DOI: 10.1097/mpg.0000000000003337] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 07/06/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate neurodevelopmental status among children with inherited cholestatic liver diseases with native liver and variables predictive of impairment. METHODS Participants with Alagille syndrome (ALGS), progressive familial intrahepatic cholestasis (PFIC), and alpha 1 antitrypsin deficiency (A1AT) enrolled in a longitudinal, multicenter study and completed the Wechsler Preschool and Primary Scale of Intelligence-III or Intelligence Scale for Children-IV. Full Scale Intelligence Quotient (FSIQ) was analyzed continuously and categorically (>100, 85-99, 70-84, <70). Univariate linear regression was performed to study association between FSIQ and risk factors, stratified by disease. RESULTS Two hundred and fifteen completed testing (ALGS n = 70, PFIC n = 43, A1AT n = 102); median age was 7.6 years (3.0-16.9). Mean FSIQ in ALGS was lower than A1AT (94 vs 101, P = 0.01). Frequency of FSIQ < 85 (>1 standard deviation [SD] below average) was highest in ALGS (29%) versus 18.6% in PFIC and 12.8% in A1AT, and was greater than expected in ALGS based on normal distribution (29% vs 15.9%, P = 0.003). ALGS scored significantly lower than test norms in almost all Wechsler composites; A1AT scored lower on Working Memory and Processing Speed; PFIC was not different from test norms. Total bilirubin, alkaline phosphatase, albumin, hemoglobin, and parental education were significantly associated with FSIQ. CONCLUSIONS Patients with ALGS are at increased risk of lower FSIQ, whereas our data suggest A1AT and PFIC are not. A1AT and ALGS appear vulnerable to working memory and processing speed deficits suggestive of attention/executive function impairment. Malnutrition, liver disease severity, and sociodemographic factors appear related to FSIQ deficits, potentially identifying targets for early interventions.
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Affiliation(s)
- Daniel H. Leung
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Lisa G. Sorensen
- Department of Child & Adolescent Psychiatry, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Wen Ye
- Department of Biostatistics, University of Michigan
| | | | - Vicky L. Ng
- Transplant and Regenerative Medicine Center, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Kathleen M. Loomes
- Pediatric Gastroenterology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Emily M. Fredericks
- CS Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI
| | - Estella M. Alonso
- Ann and Robert H. Lurie Children's Hospital and Northwestern University, Chicago, IL
| | - James E. Heubi
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Simon P. Horslen
- Division of Gastroenterology and Hepatology, Seattle Children's, Seattle, WA
| | - Saul J. Karpen
- Pediatrics, Emory University, Children's Healthcare Atlanta, Atlanta, GA
| | - Jean P. Molleston
- Pediatric Gastroenterology, Hepatology and Nutrition, James Whitcomb Riley Hospital for Children, Indianapolis, IN
| | - Philip Rosenthal
- Pediatrics and Surgery, University of California San Francisco, San Francisco, CA
| | - Ronald J. Sokol
- Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | | | | | - Binita M. Kamath
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - John C. Magee
- Surgery, University of Michigan School of Medicine, Ann Arbor, MI
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25
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Ye W, Leung DH, Molleston JP, Ling SC, Murray KF, Nicholas JL, Huang S, Karmazyn BW, Harned RK, Masand P, Alazraki AL, Navarro OM, Otto RK, Palermo JJ, Towbin AJ, Alonso EM, Karnsakul WW, Jane Schwarzenberg S, Seidel GF, Siegel M, Magee JC, Narkewicz MR, Jay Freeman A. Association Between Transient Elastography and Controlled Attenuated Parameter and Liver Ultrasound in Children With Cystic Fibrosis. Hepatol Commun 2021; 5:1362-1372. [PMID: 34430781 PMCID: PMC8369935 DOI: 10.1002/hep4.1719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/18/2020] [Revised: 02/14/2021] [Accepted: 03/01/2021] [Indexed: 02/04/2023] Open
Abstract
Methods to identify children with cystic fibrosis (CF) at risk for development of advanced liver disease are lacking. We aim to determine the association between liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE) with research ultrasound (US) patterns and conventional hepatic markers as a potential means to follow liver disease progression in children with CF. ELASTIC (Longitudinal Assessment of Transient Elastography in CF) is a nested cohort of 141 patients, ages 7-21, enrolled in the Prediction by US of Risk of Hepatic Cirrhosis in CF (PUSH) Study. We studied the association between LSM with research-grade US patterns (normal [NL], heterogeneous [HTG], homogeneous [HMG], or nodular [NOD]) and conventional hepatic markers. In a subgroup (n = 79), the association between controlled attenuation parameter (CAP) and US pattern was explored. Among 133 subjects undergoing VCTE, NOD participants (n = 26) had a significantly higher median (interquartile range) LSM of 9.1 kPa (6.3, 15.8) versus NL (n = 72, 5.1 kPa [4.2, 7.0]; P < 0.0001), HMG (n = 17, 5.9 kPa [5.2, 7.8]; P = 0.0013), and HTG (n = 18, 6.1 kPa [4.7, 7.0]; P = 0.0008) participants. HMG participants (n = 14) had a significantly higher mean CAP (SD) (270.5 dB/m [61.1]) compared with NL (n = 40, 218.8 dB/m [46.5]; P = 0.0027), HTG (n = 10, 218.1 dB/m [60.7]; P = 0.044), and NOD (n = 15, 222.7 dB/m [56.4]; P = 0.041) participants. LSM had a negative correlation with platelet count (rs = - 0.28, P = 0.0071) and positive correlation with aspartate aminotransferase-to-platelet ratio index (rs = 0.38, P = 0.0002), Fibrosis-4 index (rs = 0.36, P = 0.0007), gamma-glutamyltransferase (GGT; rs = 0.35, P = 0.0017), GGT-to-platelet ratio (rs = 0.35, P = 0.003), and US spleen size z-score (rs = 0.27, P = 0.0073). Conclusion: VCTE is associated with US patterns and conventional markers in patients with liver disease with CF.
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Affiliation(s)
- Wen Ye
- Department of BiostatisticsUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and NutritionDepartment of PediatricsTexas Children's HospitalBaylor College of MedicineHoustonTXUSA
| | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology and NutritionRiley Hospital for Children at IU HealthIndiana University School of MedicineIndianapolisINUSA
| | - Simon C Ling
- The Hospital for Sick ChildrenDepartment of PediatricsUniversity of TorontoTorontoONCanada
| | - Karen F Murray
- Division of Gastroenterology and HepatologyUniversity of Washington and Seattle Children's HospitalSeattleWAUSA
| | - Jennifer L Nicholas
- Mallinckrodt Institute of RadiologyWashington University School of MedicineSt. LouisMOUSA
| | - Suiyuan Huang
- Department of BiostatisticsUniversity of Michigan School of Public HealthAnn ArborMIUSA
| | - Boaz W Karmazyn
- Pediatric RadiologyRiley Hospital for Children at IU HealthIndiana University School of MedicineIndianapolisINUSA
| | - Roger K Harned
- Division of Pediatric RadiologyChildren's Hospital Colorado and University of Colorado School of MedicineAuroraCOUSA
| | - Prakash Masand
- Division of RadiologyTexas Children's HospitalHoustonTXUSA
| | - Adina L Alazraki
- Department of RadiologyEmory University School of Medicine and Children's Healthcare of AtlantaAtlantaGAUSA
| | - Oscar M Navarro
- Department of Medical ImagingUniversity of TorontoTorontoONCanada.,Department of Diagnostic ImagingThe Hospital for Sick ChildrenTorontoONCanada
| | - Randolph K Otto
- Department of RadiologyUniversity of Washington and Seattle Children's HospitalSeattleWAUSA
| | - Joseph J Palermo
- Division of Pediatric Gastroenterology, Hepatology and NutritionCincinnati Children's Hospital Medical CenterCincinnatiOHUSA.,Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Alexander J Towbin
- Department of RadiologyCincinnati Children's Hospital Medical CenterCincinnatiOHUSA.,Department of RadiologyUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Estella M Alonso
- Division of Pediatric Gastroenterology, Hepatology and NutritionAnn & Robert H. Lurie Children's HospitalChicagoILUSA
| | - Wikrom W Karnsakul
- Division of Pediatric Gastroenterology, Hepatology and NutritionJohn Hopkins School of MedicineBaltimoreMDUSA
| | | | - Glenn F Seidel
- Pediatric RadiologyLucile Packard Children's HospitalPalo AltoCAUSA
| | - Marilyn Siegel
- Mallinckrodt Institute of RadiologyWashington University School of MedicineSt. LouisMOUSA
| | - John C Magee
- Department of SurgeryUniversity of Michigan Medical SchoolAnn ArborMIUSA
| | - Michael R Narkewicz
- Digestive Health InstituteChildren's Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and NutritionDepartment of PediatricsUniversity of Colorado School of MedicineAuroraCOUSA
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology and NutritionEmory University School of Medicine/Children's Healthcare of AtlantaAtlantaGAUSA
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26
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Molleston JP, Bennett WE. Mortality, Risk Factors and Disparities Associated with Esophageal Variceal Bleeding in Children's Hospitals in the US. J Pediatr 2021; 232:176-182. [PMID: 33450222 DOI: 10.1016/j.jpeds.2020.12.082] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 10/16/2020] [Revised: 12/30/2020] [Accepted: 12/31/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To use a large administrative database to determine the mortality, risk factors, and comorbidities of esophageal variceal bleeding in children. STUDY DESIGN Retrospective cohort study using Pediatric Health Information System data from 50 tertiary children's hospitals in the US. International Classification of Diseases (ICD) codes (FY 2020 ICD-10 update and revision 10 of ICD-9) from 2004 through 2019 identified children 18 years and younger with variceal bleeding and complications. Univariate analyses used the Student t -test for continuous variables (age) and the χ2 test for categorical variables (all others). A mixed-effects linear regression was performed for multiple variables. RESULTS There were 1902 patients who had 3399 encounters for esophageal variceal bleeding. The mortality rate for variceal bleeding was 7.3%, increasing to 8.8% by 6 weeks; any mortality during the study was 20.1%. Transfusion was required in 54.7% of encounters, and 42.6% were admitted to the intensive care unit. Variceal bleeding encounters were complicated by peptic ulcer disease (6.9%), bacteremia (11.4%), acute renal failure (5.1%), mechanical ventilation (18%), ascites (21.3%), and peritonitis (3.3%). Multivariable mixed-effects logistic regression showed that Black race (OR, 2.59; P < .001) or Hispanic ethnicity (OR, 2.31; P = .001), but not sex, household income, or insurance type, were associated with increased mortality. Bacteremia, peritonitis, mechanical ventilation, acute renal failure, and transfusion were associated with higher mortality (ORs of 2.29, 2.18, 1.93, 6.33, and 1.81, respectively; P < .001, .005, .011, <.001, and .005, respectively). CONCLUSIONS The 6-week mortality rate for variceal bleeding in children is 8.8%. Black or Hispanic children are at higher risk of dying. Serious morbidities associated with variceal hemorrhage impact mortality. These data can inform consideration of prophylactic or therapeutic interventions for children at risk.
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Affiliation(s)
- Jean P Molleston
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, IN.
| | - William E Bennett
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, IN; Department of Pediatrics, Division of Pediatric and Adolescent Comparative Effectiveness Research, Indiana University School of Medicine, Indianapolis, IN
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27
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Newton KP, Lavine JE, Wilson L, Behling C, Vos MB, Molleston JP, Rosenthal P, Miloh T, Fishbein MH, Jain AK, Murray KF, Schwimmer JB. Alanine Aminotransferase and Gamma-Glutamyl Transpeptidase Predict Histologic Improvement in Pediatric Nonalcoholic Steatohepatitis. Hepatology 2021; 73:937-951. [PMID: 32416645 PMCID: PMC7669708 DOI: 10.1002/hep.31317] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [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: 11/14/2019] [Revised: 03/25/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Predictive, noninvasive tools are needed to monitor key features of nonalcoholic fatty liver disease (NAFLD) in children that relate to improvement in liver histology. The purpose of this study was to evaluate the relationship between liver chemistries and liver histology using data from the CyNCh (Cysteamine Bitartrate Delayed-Release for the Treatment of NAFLD in Children) clinical trial. APPROACH AND RESULTS This study included 146 children. Improvement in liver histology, defined as decrease in nonalcoholic fatty liver disease (NAFLD) Activity Score ≥2 points without worsening of fibrosis, occurred in 43 participants (30%). There were 46 participants with borderline zone 1 nonalcoholic steatohepatitis (NASH) at baseline, with resolution in 28% (12 of 46). Multivariate models were constructed using baseline and change in alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT) at 52 weeks, for improvement in (1) liver histology primary outcome, (2) borderline zone 1 NASH, and (3) fibrosis. For improvement in histology, the model (P < 0.0001) retained baseline and change in GGT (area under the receiver operating characteristic [AUROC], 0.79; 95% confidence interval [CI], 0.71-0.87). For borderline zone 1 NASH, the model (P = 0.0004) retained baseline and change in ALT (AUROC, 0.80; 95% CI, 0.67-0.93). For fibrosis, the model (P < 0.001) retained baseline and change in ALT (AUROC, 0.80; 95% CI, 0.67-0.93). Additional clinical parameters were added to the models using Akaike's information criterion selection, and significantly boosted performance: improvement in histology with AUROC of 0.89 (95% CI, 0.82-0.95), borderline zone 1 NASH with AUROC of 0.91 (95% CI, 0.83-0.99), and fibrosis with AUROC of 0.89 (95% CI, 0.82-0.94). Models were validated using data from the TONIC (Treatment of Nonalcoholic Fatty Liver Disease in Children) trial. CONCLUSIONS In children with NAFLD, dynamic changes in serum ALT and GGT are associated with change in liver histology and appear to be powerful indicators of histological response.
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Affiliation(s)
- Kimberly P Newton
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsUniversity of California San Diego School of MedicineLa JollaCA.,Division of GastroenterologyDepartment of PediatricsRady Children's HospitalSan DiegoCA
| | - Joel E Lavine
- Division of Pediatric Gastroenterology, Hepatology and NutritionDepartment of PediatricsColumbia UniversityNew YorkNY
| | - Laura Wilson
- Department of EpidemiologyBloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMD.,Department of MedicineJohns Hopkins UniversitySchool of MedicineBaltimoreMD
| | - Cynthia Behling
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsUniversity of California San Diego School of MedicineLa JollaCA.,Department of PathologySharp Medical CenterSan DiegoCA
| | - Miriam B Vos
- Department of PediatricsEmory University School of Medicine and Children's Healthcare of AtlantaAtlantaGA
| | | | - Philip Rosenthal
- Departments of Pediatrics & SurgeryUniversity of CaliforniaSan FranciscoCA
| | - Tamir Miloh
- Department of PediatricsTexas Children's HospitalHoustonTX
| | - Mark H Fishbein
- Department of PediatricsAnn & Robert H. Lurie Children's Hospital of ChicagoChicagoIL
| | - Ajay K Jain
- Department of PediatricsSaint Louis UniversitySt. LouisMI
| | - Karen F Murray
- Department of PediatricsCleveland Clinic Children's HospitalClevelandOH
| | - Jeffrey B Schwimmer
- Division of Gastroenterology, Hepatology, and NutritionDepartment of PediatricsUniversity of California San Diego School of MedicineLa JollaCA.,Division of GastroenterologyDepartment of PediatricsRady Children's HospitalSan DiegoCA
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28
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Sarkar M, Brady CW, Fleckenstein J, Forde KA, Khungar V, Molleston JP, Afshar Y, Terrault NA. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 73:318-365. [PMID: 32946672 DOI: 10.1002/hep.31559] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/08/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Monika Sarkar
- University of California, San Francisco, San Francisco, CA
| | | | | | | | | | - Jean P Molleston
- Indiana University and Riley Hospital for Children, Indianapolis, IN
| | - Yalda Afshar
- University of California, Los Angeles, Los Angeles, CA
| | - Norah A Terrault
- Keck School of Medicine, University of Southern California, Los Angeles, CA
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29
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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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30
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Xanthakos SA, Lavine JE, Yates KP, Schwimmer JB, Molleston JP, Rosenthal P, Murray KF, Vos MB, Jain AK, Scheimann AO, Miloh T, Fishbein M, Behling CA, Brunt EM, Sanyal AJ, Tonascia J. Progression of Fatty Liver Disease in Children Receiving Standard of Care Lifestyle Advice. Gastroenterology 2020; 159:1731-1751.e10. [PMID: 32712103 PMCID: PMC7680281 DOI: 10.1053/j.gastro.2020.07.034] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [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: 11/19/2019] [Revised: 06/19/2020] [Accepted: 07/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Nonalcoholic fatty liver disease (NAFLD) is the most common pediatric chronic liver disease. Little is known about outcomes in recognized youth. METHODS We compared paired liver biopsies from 122 of 139 children with NAFLD (74% male; 64% white; 71% Hispanic; mean age, 13 ± 3 years; age range, 8-17 years) who received placebo and standard of care lifestyle advice in 2 double-blind, randomized clinical trials within the nonalcoholic steatohepatitis (NASH) clinical research network from 2005 through 2015. We analyzed histologic changes with respect to baseline and longitudinal change in clinical variables using regression analysis. RESULTS At enrollment, 31% of the children had definite NASH, 34% had borderline zone 1 NASH, 13% had borderline zone 3 NASH, and 21% had fatty liver but not NASH. Over a mean period of 1.6 ± 0.4 years, borderline or definite NASH resolved in 29% of the children, whereas 18% of the children with fatty liver or borderline NASH developed definite NASH. Fibrosis improved in 34% of the children but worsened in 23%. Any progression to definite NASH and/or in fibrosis was associated with adolescent age, and higher waist circumference, levels of alanine or aspartate aminotransferase, total and low-density lipoprotein cholesterol at baseline (<0.05), and over follow-up time, with increasing level of alanine aminotransferase, hemoglobin A1C (P<.05), gamma-glutamyl transferase and development of type 2 diabetes (P<.01). Increasing level of gamma-glutamyl transferase was also associated with reduced odds of any improvement (P = .003). CONCLUSIONS One-third of children with NAFLD enrolled in placebo groups of clinical trials had histologic features of progression within 2 years, in association with increasing obesity and serum levels of aminotransferases and loss of glucose homeostasis.
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Affiliation(s)
- Stavra A. Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joel E. Lavine
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia Vagelos College of Physicians and Surgeons, New York, New York
| | | | - Jeffrey B. Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California
| | - Jean P. Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, Indiana
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, Benioff Children’s Hospital, San Francisco, California
| | - Karen F. Murray
- Pediatrics Institute, Cleveland Clinic Children’s, Cleveland, Ohio
| | - Miriam B. Vos
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Ajay K. Jain
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, St. Louis University, St. Louis, Missouri
| | | | - Tamir Miloh
- Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Mark Fishbein
- Department of Pediatrics, Feinberg Medical School of Northwestern University, Chicago, Illinois
| | - Cynthia A. Behling
- Department of Pathology, Sharp Memorial Hospital; Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego, California
| | - Elizabeth M. Brunt
- Department of Pathology and Immunology, Washington University, St. Louis, Missouri
| | - Arun J. Sanyal
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - James Tonascia
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Shneider BL, Goodrich NP, Ye W, Sawyers C, Molleston JP, Merion RM, Leung DH, Karpen SJ, Kamath BM, Cavallo L, Wang K, Teckman JH, Squires JE, Sundaram SS, Rosenthal P, Romero R, Murray KF, Loomes KM, Jensen MK, Bezerra JA, Bass LM, Sokol RJ, Magee JC. Nonfasted Liver Stiffness Correlates with Liver Disease Parameters and Portal Hypertension in Pediatric Cholestatic Liver Disease. Hepatol Commun 2020; 4:1694-1707. [PMID: 33163838 PMCID: PMC7603532 DOI: 10.1002/hep4.1574] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/08/2020] [Accepted: 06/14/2020] [Indexed: 12/12/2022] Open
Abstract
Elastographic measurement of liver stiffness is of growing importance in the assessment of liver disease. Pediatric experiences with this technique are primarily single center and limited in scope. The Childhood Liver Disease Research Network provided a unique opportunity to assess elastography in a well-characterized multi-institutional cohort. Children with biliary atresia (BA), alpha-1 antitrypsin deficiency (A1ATD), or Alagille syndrome (ALGS) followed in a prospective longitudinal network study were eligible for enrollment in a prospective investigation of transient elastography (FibroScan). Studies were performed in participants who were nonfasted and nonsedated. Liver stiffness measurements (LSMs) were correlated with standard clinical and biochemical parameters of liver disease along with a research definition of clinically evident portal hypertension (CEPH) graded as absent, possible, or definite. Between November 2016 and August 2019, 550 participants with a mean age of 8.8 years were enrolled, 458 of whom had valid LSMs (BA, n = 254; A1ATD, n = 104; ALGS, n = 100). Invalid scans were more common in participants <2 years old. There was a positive correlation between LSM and total bilirubin, international normalized ratio (INR), aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (GGT), GGT to platelet ratio (GPR), pediatric end-stage liver disease score, AST to platelet ratio index, and spleen size, and a negative correlation with albumin and platelet count in BA, with similar correlations for A1ATD (except AST, ALT, and albumin) and ALGS (except for INR, GGT, GPR, and ALT). Possible or definite CEPH was more common in BA compared to ALGS and A1ATD. LSM was greater in definite versus absent CEPH in all three diseases. Disease-specific clinical and biochemical characteristics of the different CEPH grades were observed. Conclusion: It is feasible to obtain LSMs in children, especially over the age of 2 years. LSM correlates with liver parameters and portal hypertension, although disease-specific patterns exist.
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Affiliation(s)
| | | | - Wen Ye
- University of MichiganAnn ArborMIUSA
| | - Cindy Sawyers
- Riley Hospital for ChildrenIndiana UniversityIndianapolisINUSA
| | | | - Robert M. Merion
- Arbor Research Collaborative for HealthAnn ArborMIUSA
- University of MichiganAnn ArborMIUSA
| | - Daniel H. Leung
- Baylor College of Medicine and Texas Children’s HospitalHoustonTXUSA
| | - Saul J. Karpen
- Children’s Healthcare of Atlanta and Emory University School of MedicineAtlantaGAUSA
| | - Binita M. Kamath
- The Hospital for Sick Children and the University of TorontoTorontoCanada
| | - Laurel Cavallo
- Baylor College of Medicine and Texas Children’s HospitalHoustonTXUSA
| | - Kasper Wang
- Children’s Hospital Los AngelesTorontoCanada
| | | | | | - Shikha S. Sundaram
- University of Colorado School of MedicineChildren’s Hospital ColoradoPittsburghPAUSA
| | | | - Rene Romero
- Children’s Healthcare of Atlanta and Emory University School of MedicineAtlantaGAUSA
| | - Karen F. Murray
- Seattle Children’s Hospital and the University of Washington School of MedicineSeattleWAUSA
| | - Kathleen M. Loomes
- The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of PennsylvaniaPhiladelphiaPAUSA
| | - M. Kyle Jensen
- Primary Children’s Hospital and University of UtahSalt Lake CityUTUSA
| | | | - Lee M. Bass
- Ann and Robert H. Lurie Children's Hospital and Northwestern UniversityChicagoILUSA
| | - Ronald J. Sokol
- University of Colorado School of MedicineChildren’s Hospital ColoradoPittsburghPAUSA
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McPheron MA, Craven HJ, Molleston JP, Dilly CK. Genetic Testing and Counseling in Metabolic Liver Disease: An Interactive Lecture for Medical Students. MedEdPORTAL 2020; 16:10996. [PMID: 33117886 PMCID: PMC7586753 DOI: 10.15766/mep_2374-8265.10996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 06/01/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Medical students have limited opportunities to learn about current genetic testing. This session provided exposure to different types of testing and the complex issues that physicians may encounter when counseling patients on proper testing and interpreting results. METHODS We designed a 1-hour interactive lecture for second-year medical students. We presented an overview of the topic, then applied the concepts to specific disorders and cases. Students were asked to answer questions regarding cases using an audience response system, and we used their responses as the basis for our in-class discussion. This session has been held twice, with 25 students attending in 2018 and 31 students in 2019. The session was also recorded so that additional students not in attendance could watch, and was available to 151 students in 2018 and 333 students in 2019. RESULTS Students answered questions via audience response system. There was a range of 47%-100% of students giving the correct answers in 2018, and 55%-93% in 2019. Exam questions covering genetic counseling issues were answered correctly by 66% and 77% of students in 2018, and 70% and 68% of students in 2019. DISCUSSION This session provided an opportunity for medical students to be exposed to some of the complex ethical and psychosocial issues that may arise with genetic testing for liver disease and to consider how to navigate them. Using an audience response system during the lecture made the session more interactive and allowed the teacher to correct errors and teach based on the responses.
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Affiliation(s)
- Molly A. McPheron
- Assistant Professor, Medical and Molecular Genetics, Indiana University School of Medicine
| | - Hannah J. Craven
- Assistant Librarian, Ruth Lilly Medical Library, Indiana University School of Medicine
| | - Jean P. Molleston
- Professor of Clinical Pediatrics, Department of Pediatrics, Indiana University School of Medicine
| | - Christen K. Dilly
- Assistant Professor, Department of Medicine, Indiana University School of Medicine; Roudebush VA Medical Center
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Venkat V, Ng VL, Magee JC, Ye W, Hawthorne K, Harpavat S, Molleston JP, Murray KF, Wang KS, Soufi N, Bass LM, Alonso EM, Bezerra JA, Jensen MK, Kamath BM, Loomes KM, Mack CL, Rosenthal P, Shneider BL, Squires RH, Sokol RJ, Karpen SJ. Modeling Outcomes in Children With Biliary Atresia With Native Liver After 2 Years of Age. Hepatol Commun 2020; 4:1824-1834. [PMID: 33305153 PMCID: PMC7706301 DOI: 10.1002/hep4.1602] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 06/24/2020] [Revised: 07/21/2020] [Accepted: 07/31/2020] [Indexed: 12/15/2022] Open
Abstract
Approximately 50% of infants with biliary atresia (BA) undergoing Kasai portoenterostomy show survival with native liver (SNL) at age 2 years. Predictors of disease progression after age 2 years are unknown, despite estimates of 20%-30% undergoing liver transplant (LT) between age 2 and 18 years. We sought to address this knowledge gap by developing prognostic models in participants of the multicenter prospective National Institutes of Health-supported Childhood Liver Disease Research Network. We extracted 14 clinical and biochemical variables at age 2 years to develop two models for future outcomes: 1) LT or death (LTD) and 2) first sentinel event (SE), either new onset ascites, hepatopulmonary syndrome (HPS), or gastrointestinal (GI) bleed. A total of 240 participants, enrolled between 2004 and 2017, were followed until a median age of 5.1 years (range, 2.0-13.3 years). Of these participants, 38 underwent LT (n = 37) or death (n = 1); cumulative incidence, 23.7% (95% confidence interval [CI], 16.2%-32.0%). Twenty-seven experienced either new-onset ascites (n = 13), HPS (n = 1), or GI bleed (n = 14). One participant had ascites and GI bleed concurrently; cumulative incidence, 21.5% (95% CI, 14.2%-29.8%) by age 10 years. The Cox proportional hazard model predicted risk of LTD, using total bilirubin, albumin, platelet count, and history of either ascites or cholangitis (BA LTD model), with a C-index of 0.88 (range, 0.86-0.89). A cause-specific hazard competing risk model predicted SE using platelet count and gamma glutamyltransferase levels (BA SE model) with a C-index of 0.81 (range, 0.80-0.84). Internal model validity was assessed using Harrell's C-index with cross-validation. Conclusion: Stratification using these models identified risk of poor outcomes in patients with BA SNL after age 2 years. The models may identify those who would benefit from enhanced clinical surveillance and prioritization in clinical trials.
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Affiliation(s)
- Veena Venkat
- UPMC Children's Hospital of Pittsburgh Pittsburgh PA
| | - Vicky L Ng
- Hospital for Sick Children University of Toronto Toronto Canada
| | - John C Magee
- University of Michigan Hospitals and Health Centers Ann Arbor MI
| | - Wen Ye
- University of Michigan Hospitals and Health Centers Ann Arbor MI
| | | | - Sanjiv Harpavat
- Texas Children's Hospital Liver Center, Baylor College of Medicine Houston TX
| | | | | | | | | | - Lee M Bass
- Ann & Robert H. Lurie Children's Hospital of Chicago Chicago IL
| | | | | | - M Kyle Jensen
- University of Utah School of Medicine Primary Children's Hospital Salt Lake City UT
| | - Binita M Kamath
- Hospital for Sick Children University of Toronto Toronto Canada
| | | | - Cara L Mack
- University of Colorado School of Medicine Children's Hospital Colorado Aurora CO
| | | | - Benjamin L Shneider
- Texas Children's Hospital Liver Center, Baylor College of Medicine Houston TX
| | | | - Ronald J Sokol
- University of Colorado School of Medicine Children's Hospital Colorado Aurora CO
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Shiau H, Guffey D, Loomes KM, Seidman C, Ragozzino E, Molleston JP, Schady D, Leung DH. Biopsy Validated Study of Biomarkers for Liver Fibrosis and Transplant Prediction in Inherited Cholestasis. Hepatol Commun 2020; 4:1516-1526. [PMID: 33024920 PMCID: PMC7527690 DOI: 10.1002/hep4.1569] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 03/31/2020] [Revised: 05/29/2020] [Accepted: 06/18/2020] [Indexed: 12/12/2022] Open
Abstract
Alagille syndrome (ALGS) and progressive familial intrahepatic cholestasis (PFIC) are inherited cholestatic disorders with risk of developing end‐stage liver disease requiring liver transplantation (LT). We investigated aspartate aminotransferase‐to‐platelet ratio index (APRI), Fibrosis‐4 score (FIB‐4), and conjugated bilirubin as biomarkers to assess fibrosis severity and risk for LT among children with ALGS and PFIC. This multicenter, cross‐sectional study included 64 children with ALGS or PFIC (per genetics or strict clinical criteria) with APRI, FIB‐4, and conjugated bilirubin levels collected within ±90 days of their most recent liver biopsy. A single, blinded pathologist staged all biopsies (metavir; F0‐F2: nonsevere, F3‐F4: severe). Logistic regression and area under the receiver operating characteristic curve analysis (AUC) were used to assess biomarker associations with fibrosis severity and risk for LT. In ALGS, only APRI distinguished F3‐F4 (AUC 0.72, P = 0.012), with a cutoff greater than 2.97 demonstrating a sensitivity of 61.5% (95% confidence interval 0.32, 0.86) and specificity of 81.5% (0.62, 0.94). In ALGS, a 50% increase of APRI increased the odds of F3‐F4 by 1.31‐fold (1.04, 1.65; P = 0.023). In ALGS, APRI (AUC 0.87; P < 0.001) and FIB‐4 (AUC 0.84; P < 0.001) were able to predict risk for LT. In PFIC, only APRI distinguished F3‐4 (AUC 0.74, P = 0.039), with a cutoff greater than 0.99 demonstrating a sensitivity of 80% (0.44, 0.98) and specificity of 64.3% (0.35, 0.87). In PFIC, only FIB‐4 was able predict risk for LT (AUC 0.80; P = 0.002). In ALGS or PFIC, conjugated bilirubin could not distinguish F3‐F4 or predict risk for LT. Conclusion: This liver biopsy–validated study suggests that APRI is able to distinguish F3‐F4 from F0‐F2 in ALGS and PFIC. APRI and FIB‐4 may also serve as predictors of risk for LT in ALGS (APRI and FIB‐4) and PFIC (FIB‐4).
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Affiliation(s)
- Henry Shiau
- Pediatric Gastroenterology, Hepatology, and Nutrition Baylor College of Medicine Houston TX.,Texas Children's Hospital Houston TX
| | - Danielle Guffey
- Institute for Clinical and Translational Research Baylor College of Medicine Houston TX
| | - Kathleen M Loomes
- Pediatric Gastroenterology, Hepatology, and Nutrition University of Pennsylvania Perelman School of Medicine Philadelphia PA.,Children's Hospital of Philadelphia Philadelphia PA
| | | | | | - Jean P Molleston
- Pediatric Gastroenterology, Hepatology, and Nutrition Indiana University-Riley Hospital for Children Indianapolis IN
| | - Deborah Schady
- Pathology and Immunology Baylor College of Medicine Houston TX
| | - Daniel H Leung
- Pediatric Gastroenterology, Hepatology, and Nutrition Baylor College of Medicine Houston TX.,Texas Children's Hospital Houston TX
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Abstract
INTRODUCTION No published curricula exist to introduce medical students to drug-induced liver injury (DILI). However, DILI is the most common cause of acute liver failure in the US, and drug-drug interactions are tested on the USMLE Step 1. METHODS We developed an independent study module to introduce students to DILI. This module consisted of a narrated PowerPoint introduction, a journal article, and four example cases. Students completed the module independently. To evaluate the effectiveness of the activity, exam data and responses to the cases were reviewed, and end-of-course survey data were used. These responses were used to modify questions for clarity and to develop a feedback rubric. RESULTS Mean scores on case-related questions in the module ranged from 44% to 73%. However, mean scores on test questions related to DILI ranged from 61% to 98%. It is possible that students learned from receiving feedback in the form of correct answers to the cases. On course evaluations, 52.4% of students agreed or strongly agreed that the online modules as a group (which included the DILI module) were an effective teaching method. DISCUSSION This module introduces students to DILI and enables them to interact with valuable resources. We hope that modifications will improve the learning experience and effectiveness of the module. Going forward, we plan to collect validity evidence for the feedback rubric and develop an advanced version of the module for gastroenterology fellows.
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Affiliation(s)
- Christen K. Dilly
- Assistant Professor, Department of Medicine, Indiana University School of Medicine; Staff Physician, Roudebush VA Medical Center
| | - Hannah J. Craven
- Assistant Librarian, Ruth Lilly Medical Library, Indiana University School of Medicine
| | - Jean P. Molleston
- Professor of Clinical Pediatrics, Department of Pediatrics, Indiana University School of Medicine
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Kamath BM, Spino C, McLain R, Magee JC, Fredericks EM, Setchell KD, Miethke A, Molleston JP, Mack CL, Squires RH, Alonso EM, Murray KF, Loomes KM, Kyle Jensen M, Karpen SJ, Rosenthal P, Thomas D, Sokol RJ, Shneider BL. Unraveling the Relationship Between Itching, Scratch Scales, and Biomarkers in Children With Alagille Syndrome. Hepatol Commun 2020; 4:1012-1018. [PMID: 32626833 PMCID: PMC7327199 DOI: 10.1002/hep4.1522] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 12/20/2019] [Revised: 02/12/2020] [Accepted: 02/15/2020] [Indexed: 11/21/2022] Open
Abstract
Pruritus is a debilitating symptom for patients with Alagille syndrome (ALGS). In a previously reported trial of maralixibat, an investigational antipruritic agent, itching was assessed using a digital diary based on twice‐daily caregiver observation of itching severity (Itch Reported Outcome, ItchRO[Observer]). The goal of this study was to characterize pruritus in participants with ALGS at baseline in this trial, as assessed by the ItchRO instrument and the physician‐observed clinician scratch scale (CSS), relative to biomarkers putatively associated with pruritus and health‐related quality of life assessment. Thirty‐seven participants with ALGS (median age of 6 years; range 1‐17 years) were enrolled. No association was identified between CSS and ItchRO(Obs) (r = 0.22, P = 0.2). Neither CSS nor ItchRO were associated with serum bile acids (r = −0.08, P = 0.6 for both) or autotaxin (r = 0.22, P = 0.2; r = 0.28, P = 0.12). There was no significant association between Pediatric Quality of Life Inventory total parent scores and CSS or ItchRO (r = −0.23, P = 0.2; r = −0.16, P = 0.36). There was a significant association between ItchRO and Multidimensional Fatigue Scale and Family Impact Module total scores (Pearson correlation coefficient −0.575, P = 0.0005; 0.504, P = 0.002). In exploratory analysis, selected questions relating to fatigue and sleep disturbance (n = 12) from Pediatric Quality of Life Inventory, Multidimensional Fatigue Scale, and Family Impact Module were correlated with pruritus scores; positive associations were identified. Conclusion: Itching scores did not correlate with each other, nor with putative serum biomarkers of pruritus, and further, did not correlate with quality of life. Hypothesis‐generating analyses implicate sleep disturbance and fatigue as key associations with caregiver observations of itching. This is highly relevant to the selection of surrogate endpoints for clinical trials of pruritus therapies.
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Affiliation(s)
- Binita M Kamath
- The Hospital for Sick Children University of Toronto Toronto ON Canada
| | - Cathie Spino
- School of Public Health University of Michigan Ann Arbor MI
| | - Richard McLain
- School of Public Health University of Michigan Ann Arbor MI
| | | | - Emily M Fredericks
- Child Health Evaluation and Research (CHEAR) Center University of Michigan Ann Arbor MI
| | | | | | | | - Cara L Mack
- Children's Hospital Colorado University of Colorado School of Medicine Aurora CO
| | | | - Estella M Alonso
- Ann and Robert H. Lurie Children's Hospital Northwestern University Chicago IL
| | - Karen F Murray
- Seattle Children's Hospital University of Washington School of Medicine Seattle WA
| | - Kathleen M Loomes
- The Children's Hospital of Philadelphia Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - M Kyle Jensen
- Primary Children's Hospital University of Utah Salt Lake UT
| | - Saul J Karpen
- Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | | | | | - Ronald J Sokol
- Children's Hospital Colorado University of Colorado School of Medicine Aurora CO
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Rosenthal P, Narkewicz MR, Yao BB, Jolley CD, Lobritto SJ, Wen J, Molleston JP, Hsu EK, Jonas MM, Zha J, Liu L, Leung DH. Ombitasvir, Paritaprevir, Ritonavir, and Dasabuvir Mini-Tabs Plus Ribavirin for Children Aged 3-11 Years with Hepatitis C Genotype 1a. Adv Ther 2020; 37:3299-3310. [PMID: 32451952 PMCID: PMC7467405 DOI: 10.1007/s12325-020-01389-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Indexed: 12/21/2022]
Abstract
Introduction To assess the safety, efficacy, and pharmacokinetics of mini-tablet formulations of ombitasvir (OBV), paritaprevir (PTV), ritonavir, and dasabuvir (DSV) with or without ribavirin for 12 weeks in children infected with chronic hepatitis C virus (HCV) genotype (GT) 1. Methods This is an ongoing, open-label, Phase 2/3 study in children 3–11 years old infected with HCV GT1 who were HCV treatment-naïve and non-cirrhotic. Pediatric mini-tablet formulations of OBV, PTV, ritonavir, and DSV plus ribavirin oral solution were administered for 12 weeks based on body weight. Endpoints included SVR12, adverse events (AEs), and pharmacokinetic parameters. Results Overall, 26 children received OBV, PTV, ritonavir, and DSV plus ribavirin; 14 were 3–8 years old and 12 were 9–11 years old; 35% were male; and all had chronic HCV GT1a infection. The SVR12 rate was 96% (25/26; 95% CI 81.1–99.3), with 1 child failing to achieve SVR12 due to non-adherence and treatment discontinuation. Treatment-emergent AEs of Grade ≥ 3 occurred in 3 children; 2 events in 1 child were considered serious; and none were considered treatment-related. No AEs led to discontinuation of study treatment. The most common AEs were headache (27%), fatigue (23%), pyrexia (19%), and vomiting (19%). Pharmacokinetic results showed mini-tablet formulations of OBV, PTV, DSV, and ritonavir drug exposures were comparable to the adult formulation. Conclusion The mini-tablet combination of OBV, PTV, ritonavir, and DSV plus ribavirin to treat HCV GT1a infection for 12 weeks was highly effective and suitable in children 3–11 years of age. Trial Registration ClinicalTrials.gov identifier, NCT02486406. Electronic supplementary material The online version of this article (10.1007/s12325-020-01389-9) contains supplementary material, which is available to authorized users.
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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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Kamath BM, Ye W, Goodrich NP, Loomes KM, Romero R, Heubi JE, Leung DH, Spinner NB, Piccoli DA, Alonso EM, Guthery SL, Karpen SJ, Mack CL, Molleston JP, Murray KF, Rosenthal P, Squires JE, Teckman J, Wang KS, Thompson R, Magee JC, Sokol RJ. Outcomes of Childhood Cholestasis in Alagille Syndrome: Results of a Multicenter Observational Study. Hepatol Commun 2020; 4:387-398. [PMID: 33313463 PMCID: PMC7049675 DOI: 10.1002/hep4.1468] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [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: 09/23/2019] [Accepted: 11/19/2019] [Indexed: 01/04/2023] Open
Abstract
Alagille syndrome (ALGS) is an autosomal dominant multisystem disorder with cholestasis as a defining clinical feature. We sought to characterize hepatic outcomes in a molecularly defined cohort of children with ALGS‐related cholestasis. Two hundred and ninety‐three participants with ALGS with native liver were enrolled. Participants entered the study at different ages and data were collected retrospectively prior to enrollment, and prospectively during the study course. Genetic analysis in 206 revealed JAGGED1 mutations in 91% and NOTCH2 mutations in 4%. Growth was impaired with mean height and weight z‐scores of <−1.0 at all ages. Regression analysis revealed that every 10 mg/dL increase in total bilirubin was associated with a decrease in height z‐score by 0.10 (P = 0.03) and weight z‐score by 0.15 (P = 0.007). Total bilirubin was higher for younger participants (P = 0.03) with a median of 6.9 mg/dL for those less than 1 year old compared with a median of 1.3 mg/dL for participants 13 years or older. The median gamma glutamyl transferase also dropped from 612 to 268 in the same age groups. After adjusting for age, there was substantial within‐individual variation of alanine aminotransferase. By 20 years of age, 40% of participants had developed definite portal hypertension. Estimated liver transplant–free survival at the age of 18.5 years was 24%. Conclusions: This is the largest multicenter natural history study of cholestasis in ALGS, demonstrating a previously underappreciated burden of liver disease with early profound cholestasis, a second wave of portal hypertension later in childhood, and less than 25% of patients reaching young adulthood with their native liver. These findings will promote optimization of ALGS management and development of clinically relevant endpoints for future therapeutic trials.
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Affiliation(s)
- Binita M Kamath
- The Hospital for Sick Children University of Toronto Toronto ON Canada
| | - Wen Ye
- Department of Surgery University of Michigan Ann Arbor MI
| | | | - Kathleen M Loomes
- The Children's Hospital of Philadelphia Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Rene Romero
- Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | - James E Heubi
- Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Daniel H Leung
- Baylor College of Medicine Texas Children's Hospital Houston TX
| | - Nancy B Spinner
- The Children's Hospital of Philadelphia Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - David A Piccoli
- The Children's Hospital of Philadelphia Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Estella M Alonso
- Ann and Robert H. Lurie Children's Hospital Northwestern University Chicago IL
| | | | - Saul J Karpen
- Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | - Cara L Mack
- University of Colorado School of Medicine Children's Hospital Colorado Aurora CO
| | | | - Karen F Murray
- Seattle Children's Hospital University of Washington School of Medicine Seattle WA
| | - Philip Rosenthal
- Department of Pediatrics University of California, San Francisco San Francisco CA
| | - James E Squires
- Department of Gastroenterology and Hepatology UPMC Children's Hospital of Pittsburgh Pittsburgh PA
| | - Jeffrey Teckman
- Department of Pediatrics Saint Louis University School of Medicine St. Louis MO
| | - Kasper S Wang
- Department of Surgery Children's Hospital Los Angeles Los Angeles CA
| | - Richard Thompson
- Institute of Liver Studies King's College London London United Kingdom
| | - John C Magee
- Department of Surgery University of Michigan Ann Arbor MI
| | - Ronald J Sokol
- University of Colorado School of Medicine Children's Hospital Colorado Aurora CO
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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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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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42
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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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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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Harlow KE, Africa JA, Wells A, Belt PH, Behling CA, Jain AK, Molleston JP, Newton KP, Rosenthal P, Vos MB, Xanthakos SA, Lavine JE, Schwimmer JB. Clinically Actionable Hypercholesterolemia and Hypertriglyceridemia in Children with Nonalcoholic Fatty Liver Disease. J Pediatr 2018; 198:76-83.e2. [PMID: 29661561 PMCID: PMC6019181 DOI: 10.1016/j.jpeds.2018.02.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 11/30/2017] [Revised: 01/19/2018] [Accepted: 02/14/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the percentage of children with nonalcoholic fatty liver disease (NAFLD) in whom intervention for low-density lipoprotein cholesterol or triglycerides was indicated based on National Heart, Lung, and Blood Institute guidelines. STUDY DESIGN This multicenter, longitudinal cohort study included children with NAFLD enrolled in the National Institute of Diabetes and Digestive and Kidney Diseases Nonalcoholic Steatohepatitis Clinical Research Network. Fasting lipid profiles were obtained at diagnosis. Standardized dietary recommendations were provided. After 1 year, lipid profiles were repeated and interpreted according to National Heart, Lung, and Blood Institute Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction. Main outcomes were meeting criteria for clinically actionable dyslipidemia at baseline, and either achieving lipid goal at follow-up or meeting criteria for ongoing intervention. RESULTS There were 585 participants, with a mean age of 12.8 years. The prevalence of children warranting intervention for low-density lipoprotein cholesterol at baseline was 14%. After 1 year of recommended dietary changes, 51% achieved goal low-density lipoprotein cholesterol, 27% qualified for enhanced dietary and lifestyle modifications, and 22% met criteria for pharmacologic intervention. Elevated triglycerides were more prevalent, with 51% meeting criteria for intervention. At 1 year, 25% achieved goal triglycerides with diet and lifestyle changes, 38% met criteria for advanced dietary modifications, and 37% qualified for antihyperlipidemic medications. CONCLUSIONS More than one-half of children with NAFLD met intervention thresholds for dyslipidemia. Based on the burden of clinically relevant dyslipidemia, lipid screening in children with NAFLD is warranted. Clinicians caring for children with NAFLD should be familiar with lipid management.
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Affiliation(s)
- Kathryn E Harlow
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pediatrics, Division of Gastroenterology, Rady Children's Hospital, San Diego, CA
| | - Jonathan A Africa
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pediatrics, Division of Gastroenterology, Rady Children's Hospital, San Diego, CA
| | - Alan Wells
- Department of Pediatrics, Division of Dysmorphology and Teratology, University of California, San Diego, CA
| | - Patricia H Belt
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Cynthia A Behling
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pathology, Sharp Medical Center, San Diego, CA
| | - Ajay K Jain
- Department of Pediatrics, St. Louis University, St. Louis, MO
| | - Jean P Molleston
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, IN
| | - Kimberly P Newton
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pediatrics, Division of Gastroenterology, Rady Children's Hospital, San Diego, CA
| | - Philip Rosenthal
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California, San Francisco Benioff Children's Hospital, San Francisco, CA
| | - Miriam B Vos
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Stavra A Xanthakos
- Steatohepatitis Center, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Joel E Lavine
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University, New York, NY
| | - Jeffrey B Schwimmer
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pediatrics, Division of Gastroenterology, Rady Children's Hospital, San Diego, CA.
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Rausch JC, Lavine JE, Chalasani N, Guo X, Kwon S, Schwimmer JB, Molleston JP, Loomba R, Brunt EM, da Chen YDI, Goodarzi MO, Taylor KD, Yates KP, Rotter JI. Genetic Variants Associated With Obesity and Insulin Resistance in Hispanic Boys With Nonalcoholic Fatty Liver Disease. J Pediatr Gastroenterol Nutr 2018; 66:789-796. [PMID: 29470286 PMCID: PMC5916321 DOI: 10.1097/mpg.0000000000001926] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Nonalcoholic fatty liver disease (NAFLD) disproportionately affects Hispanic boys. Further, obesity and insulin resistance are major risk factors for NAFLD. No gene localization studies had been performed on children with biopsy-proven NAFLD. This study aims to identify genomic variants associated with increased adiposity and insulin resistance in a population of children with varying histologic severity of NAFLD. METHODS We conducted a genome-wide association scan (GWAS) including 624,297 single-nucleotide polymorphisms (SNPs) distributed among all 22 autosomal chromosomes in 234 Hispanic boys (up to 18 years of age) who were consecutively recruited in a prospective cohort study in the Nonalcoholic Steatohepatitis Clinical Research Network Studies. Traits were examined quantitatively using linear regression. SNPs with P value <10 and a minor allele frequency >5% were considered potentially significant. RESULTS Evaluated subjects had a median age of 12.0 years, body mass index (BMI) of 31.4, and hemoglobin A1C (Hgb A1C) of 5.3. The prevalence of NAFL, borderline NASH, and definite NASH were 23%, 53%, and 22%, respectively. The GWAS identified 10 SNPs that were associated with BMI z score, 6 within chromosome 2, and 1 within CAMK1D, which has a potential role in liver gluconeogenesis. In addition, the GWAS identified 9 novel variants associated with insulin resistance: HOMA-IR (6) and HbA1c (3). CONCLUSIONS This study of Hispanic boys with biopsy-proven NAFLD with increased risk for the metabolic syndrome revealed novel genetic variants that are associated with obesity and insulin resistance.
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Affiliation(s)
| | | | | | - Xiuqing Guo
- Institute for Translational Genomics and Population Science and Pediatrics, LA BioMed at Harbor-UCLA Medical Center, Los Angeles, CA
| | - Soonil Kwon
- Institute for Translational Genomics and Population Science and Pediatrics, LA BioMed at Harbor-UCLA Medical Center, Los Angeles, CA
| | | | | | - Rohit Loomba
- Medicine, University of California, San Diego, San Diego, CA
| | | | - Yii-Der I da Chen
- Institute for Translational Genomics and Population Science and Pediatrics, LA BioMed at Harbor-UCLA Medical Center, Los Angeles, CA
| | - Mark O Goodarzi
- Division of Endocrinology, Diabetes and Metabolism, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Kent D Taylor
- Institute for Translational Genomics and Population Science and Pediatrics, LA BioMed at Harbor-UCLA Medical Center, Los Angeles, CA
| | - Katherine P Yates
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Jerome I Rotter
- Institute for Translational Genomics and Population Science and Pediatrics, LA BioMed at Harbor-UCLA Medical Center, Los Angeles, CA
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46
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Africa JA, Behling CA, Brunt EM, Zhang N, Luo Y, Wells A, Hou J, Belt PH, Kohil R, Lavine JE, Molleston JP, Newton KP, Whitington PF, Schwimmer JB. In Children With Nonalcoholic Fatty Liver Disease, Zone 1 Steatosis Is Associated With Advanced Fibrosis. Clin Gastroenterol Hepatol 2018; 16:438-446.e1. [PMID: 28286193 PMCID: PMC5589478 DOI: 10.1016/j.cgh.2017.02.030] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [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: 09/08/2016] [Revised: 01/26/2017] [Accepted: 02/14/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Focal zone 1 steatosis, although rare in adults with nonalcoholic fatty liver disease (NAFLD), does occur in children with NAFLD. We investigated whether focal zone 1 steatosis and focal zone 3 steatosis are distinct subphenotypes of pediatric NAFLD. We aimed to determine associations between the zonality of steatosis and demographic, clinical, and histologic features in children with NAFLD. METHODS We performed a cross-sectional study of baseline data from 813 children (age <18 years; mean age, 12.8 ± 2.7 years). The subjects had biopsy-proven NAFLD and were enrolled in the Nonalcoholic Steatohepatitis Clinical Research Network. Liver histology was reviewed using the Nonalcoholic Steatohepatitis Clinical Research Network scoring system. RESULTS Zone 1 steatosis was present in 18% of children with NAFLD (n = 146) and zone 3 steatosis was present in 32% (n = 244). Children with zone 1 steatosis were significantly younger (10 vs 14 years; P < .001) and a significantly higher proportion had any fibrosis (81% vs 51%; P < .001) or advanced fibrosis (13% vs 5%; P < .001) compared with children with zone 3 steatosis. In contrast, children with zone 3 steatosis were significantly more likely to have steatohepatitis (30% vs 6% in children with zone 1 steatosis; P < .001). CONCLUSIONS Children with zone 1 or zone 3 distribution of steatosis have an important subphenotype of pediatric NAFLD. Children with zone 1 steatosis are more likely to have advanced fibrosis and children with zone 3 steatosis are more likely to have steatohepatitis. To achieve a comprehensive understanding of pediatric NAFLD, studies of pathophysiology, natural history, and response to treatment should account for the zonality of steatosis.
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Affiliation(s)
- Jonathan A. Africa
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California,Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, California
| | - Cynthia A. Behling
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California,Department of Pathology, Sharp Memorial Hospital, San Diego, CA
| | | | - Nan Zhang
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California
| | - Yunjun Luo
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California
| | - Alan Wells
- Clinical and Translational Research Institute, University of California San Diego School of Medicine, La Jolla, California
| | - Jiayi Hou
- Clinical and Translational Research Institute, University of California San Diego School of Medicine, La Jolla, California
| | | | - Rohit Kohil
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Joel E. Lavine
- Department of Pediatrics, Columbia University, New York, NY
| | - Jean P. Molleston
- Department of Pediatrics, Indiana University, Indianapolis, IN,James Whitcomb Riley Hospital, Indianapolis, IN
| | - Kimberly P. Newton
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California,Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, California
| | | | - Jeffrey B. Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California,Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, California
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47
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Ye W, Narkewicz MR, Leung DH, Karnsakul W, Murray KF, Alonso EM, Magee JC, Schwarzenberg SJ, Weymann A, Molleston JP. Variceal Hemorrhage and Adverse Liver Outcomes in Patients With Cystic Fibrosis Cirrhosis. J Pediatr Gastroenterol Nutr 2018; 66:122-127. [PMID: 28906321 PMCID: PMC5745284 DOI: 10.1097/mpg.0000000000001728] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Cirrhosis occurs in 5% to 10% of cystic fibrosis (CF) patients, often accompanied by portal hypertension. We analyzed 3 adverse liver outcomes, variceal bleeding (VB), liver transplant (LT), and liver-related death (LD), and risk factors for these in CF Foundation Patient Registry subjects with reported cirrhosis. METHODS We determined 10-year incidence rates for VB, LT, LD, and all-cause mortality (ACM), and examined risk factors using competing risk models and Cox-proportional hazard regression. RESULTS From 2003 to 2012, 943 participants (41% females, mean age 18.1 years) had newly reported cirrhosis; 24.7% required insulin, 85% had previous pseudomonas. Seventy-three subjects had reported VB: 38 with first VB and new cirrhosis reported simultaneously and 35 with VB after cirrhosis report. Ten-year cumulative VB, LT, and LD rates were 6.6% (95% confidence interval [CI]: 4.0, 9.1%), 9.9% (95% CI: 6.6%, 13.2%), and 6.9% (95% CI: 4.0%, 9.8%), respectively, with an ACM of 39.2% (95% CI: 30.8, 36.6%). ACM was not increased in subjects with VB compared to those without (hazard ratio [HR] 1.10, 95% CI: 0.59, 2.08). CF-related diabetes (HR: 3.141, 95% CI:1.56, 6.34) and VB (HR: 4.837, 95% CI: 2.33, 10.0) were associated with higher LT risk, whereas only worse lung function was associated with increased LD in multivariate analysis. Death rate among subjects with VB was 24% with LT and 20.4% with native liver. CONCLUSIONS VB is an uncommon complication of CF cirrhosis and can herald the diagnosis, but does not affect ACM. Adverse liver outcomes and ACM are frequent by 10 years after cirrhosis report.
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Affiliation(s)
| | - Michael R Narkewicz
- Digestive Health Institute, Children's Hospital Colorado and University of Colorado School of Medicine
| | - Daniel H Leung
- Baylor College of Medicine and Texas Children's Hospital
| | | | - Karen F Murray
- Seattle Children's Hospital and University of Washington
| | | | | | | | | | - Jean P Molleston
- Indiana University School of Medicine/Riley Hospital for Children
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48
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Perito ER, Ajmera V, Bass NM, Rosenthal P, Lavine JE, Schwimmer JB, Yates KP, Diehl AM, Molleston JP, Murray KF, Scheimann A, Gill R, Glidden D, Aouizerat B. Association Between Cytokines and Liver Histology in Children with Nonalcoholic Fatty Liver Disease. Hepatol Commun 2017; 1:609-622. [PMID: 29130075 PMCID: PMC5679472 DOI: 10.1002/hep4.1068] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Reliable non-invasive markers to characterize inflammation, hepatocellular ballooning, and fibrosis in nonalcoholic fatty liver disease (NAFLD) are lacking. We investigated the relationship between plasma cytokine levels and features of NAFLD histology to gain insight into cellular pathways driving NASH and to identify potential non-invasive discriminators of NAFLD severity and pattern. Methods Cytokines were measured from plasma obtained at enrollment in pediatric participants in NASH Clinical Research Network studies with liver biopsy-proven NAFLD. Cytokines were chosen a priori as possible discriminators of NASH and its components. Minimization of Akaike Information Criterion (AIC) was used to determine cytokines retained in multivariable models. Results Of 235 subjects, 31% had "Definite NASH" on liver histology, 43% had "Borderline NASH", and 25% had NAFLD but not NASH. Total plasminogen activator inhibitor 1 (PAI1) and activated PAI1 levels were higher in pediatric participants with Definite NASH and with lobular inflammation. Interleukin-8 (IL-8) was higher in those with stage 3-4 fibrosis and lobular inflammation. sIL-2rα was higher in children with stage 3-4 fibrosis and portal inflammation. In multivariable analysis, PAI1 variables were discriminators of Borderline/Definite NASH, definite NASH, lobular inflammation and ballooning. IL-8 increased with steatosis and fibrosis severity; sIL-2rα increased with fibrosis severity and portal inflammation. IL-7 decreased with portal inflammation and fibrosis severity. Conclusions Plasma cytokines associated with histology varied considerably among NASH features, suggesting promising avenues for investigation. Future, more targeted analysis is needed to identify the role of these markers in NAFLD and to evaluate their potential as non-invasive discriminators of disease severity.
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Affiliation(s)
- Emily R Perito
- University of California, San Francisco, San Francisco, CA
| | - Veeral Ajmera
- University of California, San Francisco, San Francisco, CA
| | - Nathan M Bass
- University of California, San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | | | | - Ryan Gill
- University of California, San Francisco, San Francisco, CA
| | - David Glidden
- University of California, San Francisco, San Francisco, CA
| | - Bradley Aouizerat
- University of California, San Francisco, San Francisco, CA.,New York University, New York, NY
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49
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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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50
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Schwimmer JB, Lavine JE, Wilson LA, Neuschwander-Tetri BA, Xanthakos SA, Kohli R, Barlow SE, Vos MB, Karpen SJ, Molleston JP, Whitington PF, Rosenthal P, Jain AK, Murray KF, Brunt EM, Kleiner DE, Van Natta ML, Clark JM, Tonascia J, Doo E. In Children With Nonalcoholic Fatty Liver Disease, Cysteamine Bitartrate Delayed Release Improves Liver Enzymes but Does Not Reduce Disease Activity Scores. Gastroenterology 2016; 151:1141-1154.e9. [PMID: 27569726 PMCID: PMC5124386 DOI: 10.1053/j.gastro.2016.08.027] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [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: 02/18/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND & AIMS No treatment for nonalcoholic fatty liver disease (NAFLD) has been approved by regulatory agencies. We performed a randomized controlled trial to determine whether 52 weeks of cysteamine bitartrate delayed release (CBDR) reduces the severity of liver disease in children with NAFLD. METHODS We performed a double-masked trial of 169 children with NAFLD activity scores of 4 or higher at 10 centers. From June 2012 to January 2014, the patients were assigned randomly to receive CBDR or placebo twice daily (300 mg for patients weighing ≤65 kg, 375 mg for patients weighing >65 to 80 kg, and 450 mg for patients weighing >80 kg) for 52 weeks. The primary outcome from the intention-to-treat analysis was improvement in liver histology over 52 weeks, defined as a decrease in the NAFLD activity score of 2 points or more without worsening fibrosis; patients without biopsy specimens from week 52 (17 in the CBDR group and 6 in the placebo group) were considered nonresponders. We calculated the relative risks (RR) of improvement using a stratified Cochran-Mantel-Haenszel analysis. RESULTS There was no significant difference between groups in the primary outcome (28% of children in the CBDR group vs 22% in the placebo group; RR, 1.3; 95% confidence interval [CI], 0.8-2.1; P = .34). However, children receiving CBDR had significant changes in prespecified secondary outcomes: reduced mean levels of alanine aminotransferase (reduction, 53 ± 88 U/L vs 8 ± 77 U/L in the placebo group; P = .02) and aspartate aminotransferase (reduction, 31 ± 52 vs 4 ± 36 U/L in the placebo group; P = .008), and a larger proportion had reduced lobular inflammation (36% in the CBDR group vs 21% in the placebo group; RR, 1.8; 95% CI, 1.1-2.9; P = .03). In a post hoc analysis of children weighing 65 kg or less, those taking CBDR had a 4-fold better chance of histologic improvement (observed in 50% of children in the CBDR group vs 13% in the placebo group; RR, 4.0; 95% CI, 1.3-12.3; P = .005). CONCLUSIONS In a randomized trial, we found that 1 year of CBDR did not reduce overall histologic markers of NAFLD compared with placebo in children. Children receiving CBDR, however, had significant reductions in serum aminotransferase levels and lobular inflammation. ClinicalTrials.gov no: NCT01529268.
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Affiliation(s)
- Jeffrey B Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, California; Department of Gastroenterology, Rady Children's Hospital, San Diego, California.
| | - Joel E Lavine
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University, and Morgan Stanley Children's Hospital of New York Presbyterian, New York, New York
| | - Laura A Wilson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Stavra A Xanthakos
- Steatohepatitis Center, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rohit Kohli
- Steatohepatitis Center, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sarah E Barlow
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Miriam B Vos
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Saul J Karpen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Jean P Molleston
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, Indiana
| | - Peter F Whitington
- Department of Pediatrics, Feinberg Medical School of Northwestern University and the Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, San Francisco, California
| | - Ajay K Jain
- Department of Pediatrics, St. Louis University, St. Louis, Missouri
| | - Karen F Murray
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's, Seattle, Washington
| | - Elizabeth M Brunt
- Department of Pathology, Washington University in St. Louis, St. Louis, Missouri
| | | | - Mark L Van Natta
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeanne M Clark
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - James Tonascia
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Edward Doo
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
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