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Robbins J, Halegoua-DeMarzio D, Basu Mallick A, Vijayvergia N, Ganetzky R, Lavu H, Giri VN, Miller J, Maley W, Shah AP, DiMeglio M, Ambelil M, Yu R, Sato T, Lefler DS. Liver Transplantation in a Woman with Mahvash Disease. N Engl J Med 2023; 389:1972-1978. [PMID: 37991855 DOI: 10.1056/nejmoa2303226] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Mahvash disease is an exceedingly rare genetic disorder of glucagon signaling characterized by hyperglucagonemia, hyperaminoacidemia, and pancreatic α-cell hyperplasia. Although there is no known definitive treatment, octreotide has been used to decrease systemic glucagon levels. We describe a woman who presented to our medical center after three episodes of small-volume hematemesis. She was found to have hyperglucagonemia and pancreatic hypertrophy with genetically confirmed Mahvash disease and also had evidence of portal hypertension (recurrent portosystemic encephalopathy and variceal hemorrhage) in the absence of cirrhosis. These findings established a diagnosis of portosinusoidal vascular disease, a presinusoidal type of portal hypertension previously known as noncirrhotic portal hypertension. Liver transplantation was followed by normalization of serum glucagon and ammonia levels, reversal of pancreatic hypertrophy, and resolution of recurrent encephalopathy and bleeding varices.
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Affiliation(s)
- Justin Robbins
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Dina Halegoua-DeMarzio
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Atrayee Basu Mallick
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Namrata Vijayvergia
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Rebecca Ganetzky
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Harish Lavu
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Veda N Giri
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Jeffrey Miller
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Warren Maley
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Ashesh P Shah
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Matthew DiMeglio
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Manju Ambelil
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Run Yu
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Takami Sato
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Daniel S Lefler
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
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Van NT, Zhang K, Wigmore RM, Kennedy AI, DaSilva CR, Huang J, Ambelil M, Villagomez JH, O'Connor GJ, Longman RS, Cao M, Snook AE, Platten M, Kasenty G, Sigal LJ, Prendergast GC, Kim SV. Dietary L-Tryptophan consumption determines the number of colonic regulatory T cells and susceptibility to colitis via GPR15. Nat Commun 2023; 14:7363. [PMID: 37963876 PMCID: PMC10645889 DOI: 10.1038/s41467-023-43211-4] [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: 01/18/2023] [Accepted: 11/03/2023] [Indexed: 11/16/2023] Open
Abstract
Environmental factors are the major contributor to the onset of immunological disorders such as ulcerative colitis. However, their identities remain unclear. Here, we discover that the amount of consumed L-Tryptophan (L-Trp), a ubiquitous dietary component, determines the transcription level of the colonic T cell homing receptor, GPR15, hence affecting the number of colonic FOXP3+ regulatory T (Treg) cells and local immune homeostasis. Ingested L-Trp is converted by host IDO1/2 enzymes, but not by gut microbiota, to compounds that induce GPR15 transcription preferentially in Treg cells via the aryl hydrocarbon receptor. Consequently, two weeks of dietary L-Trp supplementation nearly double the colonic GPR15+ Treg cells via GPR15-mediated homing and substantially reduce the future risk of colitis. In addition, humans consume 3-4 times less L-Trp per kilogram of body weight and have fewer colonic GPR15+ Treg cells than mice. Thus, we uncover a microbiota-independent mechanism linking dietary L-Trp and colonic Treg cells, that may have therapeutic potential.
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Affiliation(s)
- Nguyen T Van
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA
| | - Karen Zhang
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA
| | - Rachel M Wigmore
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA
| | - Anne I Kennedy
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA
| | - Carolina R DaSilva
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA
| | - Jialing Huang
- Department of Pathology, Anatomy, & Cell Biology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Anatomic Pathology, Geisinger Medical Center, Danville, PA, USA
| | - Manju Ambelil
- Department of Pathology, Anatomy, & Cell Biology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jose H Villagomez
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA
| | - Gerald J O'Connor
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA
| | - Randy S Longman
- Jill Roberts Center for IBD, Weill Cornell Medicine, New York, NY, USA
| | - Miao Cao
- Department of Pharmacology, Physiology, & Cancer Biology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam E Snook
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA
- Department of Pharmacology, Physiology, & Cancer Biology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael Platten
- CCU Neuroimmunology and Brain Tumor Immunology, German Cancer Research Center, Heidelberg, Germany
- Department of Neurology, Medical Faculty Mannheim, MCTN, Heidelberg University, Heidelberg, Germany
- DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
| | - Gerard Kasenty
- Department of Genetics and Development, Irving Medical Center, Columbia University, NY, USA
| | - Luis J Sigal
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA
| | - George C Prendergast
- Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA
- Lankenau Institute of Medical Research, Wynnewood, PA, USA
| | - Sangwon V Kim
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
- Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA.
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