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Jonas MM, Romero R, Rosenthal P, Lin CH, Verucchi G, Wen J, Balistreri WF, Whitworth S, Bansal S, Leung DH, Narkewicz MR, Gonzalez-Peralta RP, Mangia A, Karnsakul W, Rao GS, Shao J, de Jong J, Parhy B, Osinusi A, Kersey K, Murray KF, Sokal EM, Schwarz KB. Sofosbuvir-velpatasvir in children 3-17 years old with hepatitis C virus infection. J Pediatr Gastroenterol Nutr 2024. [PMID: 38644678 DOI: 10.1002/jpn3.12045] [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: 07/27/2022] [Revised: 02/20/2023] [Accepted: 03/13/2023] [Indexed: 04/23/2024]
Abstract
BACKGROUND The safety and efficacy of sofosbuvir-velpatasvir in children aged 3-17 years with chronic hepatitis C virus (HCV) infection of any genotype were evaluated. METHODS In this Phase 2, multicenter, open-label study, patients received once daily for 12 weeks either sofosbuvir-velpatasvir 400/100 mg tablet (12-17 years), 200/50 mg low dose tablet or oral granules (3-11 years and ≥17 kg), or 150/37.5 mg oral granules (3-5 years and <17 kg). The efficacy endpoint was sustained virologic response 12 weeks after therapy (SVR12). Dose appropriateness was confirmed by intensive pharmacokinetics in each age group. FINDINGS Among 216 patients treated, 76% had HCV genotype 1% and 12% had genotype 3. Rates of SVR12 were 83% (34/41) among 3-5-year-olds, 93% (68/73) among 6-11-year-olds, and 95% (97/102) among 12-17-year-olds. Only two patients experienced virologic failure. The most common adverse events were headache, fatigue, and nausea in 12-17-year-olds; vomiting, cough, and headache in 6-11-year-olds; and vomiting in 3-5-year-olds. Three patients discontinued treatment because of adverse events. Four patients had serious adverse events; all except auditory hallucination (n = 1) were considered unrelated to study drug. Exposures of sofosbuvir, its metabolite GS-331007, and velpatasvir were comparable to those in adults in prior Phase 2/3 studies. Population pharmacokinetic simulations supported weight-based dosing for children in this age range. INTERPRETATION The pangenotypic regimen of sofosbuvir-velpatasvir is highly effective and safe in treating children 3-17 years with chronic HCV infection.
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Affiliation(s)
| | - Rene Romero
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Philip Rosenthal
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California San Francisco, Benioff Children's Hospital, San Francisco, California, USA
| | - Chuan-Hao Lin
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | | | - Jessica Wen
- University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | | | - Daniel H Leung
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Michael R Narkewicz
- School of Medicine and Children's Hospital of Colorado, University of Colorado, Aurora, Colorado, USA
| | | | - Alessandra Mangia
- Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Wikrom Karnsakul
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Girish S Rao
- Riley Hospital for Children, Indiana University School of Medicine, Indiana, Indianapolis, USA
| | - Jiang Shao
- Gilead Sciences Inc., Foster City, California, USA
| | - Jan de Jong
- Gilead Sciences Inc., Foster City, California, USA
| | | | - Anu Osinusi
- Gilead Sciences Inc., Foster City, California, USA
| | | | - Karen F Murray
- Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Etienne M Sokal
- Cliniques Universitaires Saint-Luc, Service de Gastroentérologie Hépatologie Pédiatrique, Université Catholique de Louvain, Bruxelles, Belgique
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Indolfi G, Gonzalez-Peralta RP, Jonas MM, Sayed MHE, Fischler B, Sokal E, Wirth S, Nicastro E. ESPGHAN recommendations on treatment of chronic hepatitis C virus infection in adolescents and children including those living in resource-limited settings. J Pediatr Gastroenterol Nutr 2024; 78:957-972. [PMID: 38369891 DOI: 10.1002/jpn3.12160] [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: 03/13/2023] [Revised: 08/29/2023] [Accepted: 10/25/2023] [Indexed: 02/20/2024]
Abstract
Hepatitis C virus (HCV) infection is a major cause of chronic liver disease worldwide, with more than three million viraemic adolescents and children. Treatment of adults with HCV infection and HCV-related liver disease has advanced considerably thanks to development and improvements in therapy. Direct-acting antiviral regimens are safe and effective. Three regimens with pangenotypic activity (glecaprevir/pibrentasvir, sofosbuvir/velpatasvir and sofosbuvir/velpatasvir/voxilaprevir) and three regimens with genotype-specific activity (sofosbuvir/ribavirin, sofosbuvir/ledipasvir and elbasvir/grazoprevir) have been approved with age-specific limitation for treatment of children with chronic hepatitis C by the European Medicines Agency and the United States Food and Drug Administration. The World Health Organization has set the ambitious target to eliminate hepatitis C as a major public health threat by 2030 and based its actions against HCV on the large use of direct acting antivirals. These updated European Society for Pediatric Gastroenterology, Hepatology and Nutrition recommendations on treatment of hepatitis C describe the optimal therapeutic management of adolescents and children with HCV infection including specific indications for those living in resource-limited settings.
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Affiliation(s)
- Giuseppe Indolfi
- Department NEUROFARBA University of Florence, Florence, Italy
- Paediatric and Liver Unit, Meyer Children's Hospital IRCCS, Firenze, Italy
| | - Regino P Gonzalez-Peralta
- Pediatric Gastroenterology, Hepatology and Liver Transplant, AdventHealth for Children, AdventHealth Transplant Institute, Orlando, Florida, USA
| | | | - Manal Hamdy-El Sayed
- Department of Paediatrics, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Björn Fischler
- Department of Paediatrics, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Etienne Sokal
- UCLouvain, Cliniques Universitaires St Luc, Pediatric Hepatology, Brussels, Belgium
| | - Stefan Wirth
- Department of Paediatrics, Helios University Hospital Wuppertal, Witten-Herdecke University, Germany
| | - Emanuele Nicastro
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
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Gonzalez-Peralta RP, Wirth S, Squires RH, Mutschler F, Lang T, Pawlowska M, Sluzewski W, Majda-Stanislawska E, Fischler B, Balistreri WF, Jonas MM, Blondet N, Rosenthal P, Alkhouri N, Romero R, Grandhi A, Castronuovo P, Caro L, Du L, Rosenbloom DI, Haber BA. Elbasvir/grazoprevir in children aged 3-18 years with chronic HCV genotype 1 or 4 infection: a pharmacokinetic modeling study. Hepatol Commun 2023; 7:e0031. [PMID: 36790337 PMCID: PMC9931032 DOI: 10.1097/hc9.0000000000000031] [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] [Received: 06/16/2022] [Accepted: 09/15/2022] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Approximately 3.5 million children and adolescents worldwide are chronically infected with HCV. This study uses pharmacokinetic modeling to identify pediatric doses of elbasvir/grazoprevir (EBR/GZR) that achieve plasma concentrations similar to those seen in adults receiving the approved fixed-dose combination regimen of EBR/GZR. PATIENTS AND METHODS We conducted a nonrandomized, single-arm, multicenter, open-label phase 2b trial in children and adolescents aged 3 to <18 years with chronic HCV genotype 1 or 4 infection (NCT03379506). Pharmacokinetic data were used to bridge efficacy and safety data from adults to children in a stepwise (oldest to youngest) manner. A total of 57 participants were enrolled: cohort 1 (aged 12 to <18 y), n=22; cohort 2 (aged 7 to <12 y), n=17; and cohort 3 (aged 3 to <7 y), n=18. RESULTS Steady-state plasma exposures were achieved by week 4 for EBR and GZR in all cohorts and daily dosing achieved geometric mean steady-state area under the concentration-time curve at 0-24 hours that fell within comparability bounds established for adults. All participants achieved sustained virologic response 12 weeks after completing treatment (ie, undetectable HCV RNA 12 wk following completion of treatment). Headache (n=4), fatigue (n=4), and nausea (n=2) were the most common treatment-related adverse events (all mild or moderate); no participant discontinued because of an adverse event. CONCLUSIONS Pediatric EBR/GZR pharmacokinetic models were successfully developed based on complex adult population pharmacokinetic models. At appropriate age-related doses, EBR/GZR is safe and effective in pediatric and adolescent participants with HCV infection.
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Affiliation(s)
| | - Stefan Wirth
- Helios University Hospital Wuppertal, Witten Herdecke University, Wuppertal, Germany
| | - Robert H. Squires
- University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Frauke Mutschler
- Department of Pediatric Gastroenterology and Hepatology Hannover Medical School, Hannover, Germany
| | | | | | | | | | - Bjorn Fischler
- Karolinska Institutet CLINTEC and Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Niviann Blondet
- Seattle Children’s Hospital and the University of Washington, Seattle, Washington, USA
| | - Philip Rosenthal
- University of California, San Francisco, San Francisco, California, USA
| | - Naim Alkhouri
- Texas Liver Institute, University of Texas Health, San Antonio, Texas, USA
| | - Rene Romero
- Children’s Healthcare of Atlanta and Emory University, Atlanta, Georgia, USA
| | | | | | | | - Lihong Du
- Merck & Co. Inc., Rahway, New Jersey, USA
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Kimball B, O'Melia L, Jonas MM, Cannistraro S, Kim HB. Utilization of the Boston Children's Hospital SRTR Cohort Visualization Tool to increase team understanding of reporting cohorts. Pediatr Transplant 2021; 25:e14117. [PMID: 34414641 DOI: 10.1111/petr.14117] [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: 04/26/2021] [Revised: 07/22/2021] [Accepted: 07/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND While reviewing outcomes metrics and data from the SRTR, it became apparent that prospective assessment of the SRTR reporting cohorts would be an important proactive strategy for internal quality control. It was particularly important to identify the number of patient deaths and graft failures within 1 year of transplant that would result in being flagged by the UNOS and the MPSC. METHODS A simple Microsoft Excel line graph was created to visually display retrospective, current, and future SRTR cohorts. Data provided by the SRTR CUSUM (https://securesrtr.transplant.hrsa.gov/srtr-reports/cusum-charts/) Reports and the SRTR 1 Year Expected Survival Excel Worksheet (https://securesrtr.transplant.hrsa.gov/srtr-reports/current-release/) were leveraged to identify whether programs were in jeopardy of being flagged by UNOS/MPSC for outcomes. RESULTS & CONCLUSIONS The creation of this visual tool has greatly improved team understanding of SRTR report cohorts, as well as the risk of being flagged by regulatory agencies, for adverse outcomes.
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Affiliation(s)
- Brendan Kimball
- Boston Children's Hospital Pediatric Transplant Center, Boston, MA, USA
| | - Laura O'Melia
- Boston Children's Hospital Pediatric Transplant Center, Boston, MA, USA
| | - Maureen M Jonas
- Boston Children's Hospital Pediatric Transplant Center, Boston, MA, USA
| | | | - Heung Bae Kim
- Boston Children's Hospital Pediatric Transplant Center, Boston, MA, USA
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Martinez M, Perito ER, Valentino P, Mack CL, Aumar M, Broderick A, Draijer LG, Fagundes ED, Furuya KN, Gupta N, Horslen S, Jonas MM, Kamath BM, Kerkar N, Kim KM, Kolho KL, Koot BGP, Laborda TJ, Lee CK, Loomes KM, Miloh T, Mogul D, Mohammed S, Ovchinsky N, Rao G, Ricciuto A, Schwarz KB, Smolka V, Tanaka A, Tessier MEM, Venkat VL, Vitola BE, Woynarowski M, Zerofsky M, Deneau MR, Deneau MR. Recurrence of Primary Sclerosing Cholangitis After Liver Transplant in Children: An International Observational Study. Hepatology 2021; 74:2047-2057. [PMID: 34008252 PMCID: PMC8530456 DOI: 10.1002/hep.31911] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 02/08/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Recurrent primary sclerosing cholangitis (rPSC) following liver transplant (LT) has a negative impact on graft and patient survival; little is known about risk factors for rPSC or disease course in children. APPROACH AND RESULTS We retrospectively evaluated risk factors for rPSC in 140 children from the Pediatric PSC Consortium, a multicenter international registry. Recipients underwent LT for PSC and had >90 days of follow-up. The primary outcome, rPSC, was defined using Graziadei criteria. Median follow-up after LT was 3 years (interquartile range 1.1-6.1). rPSC occurred in 36 children, representing 10% and 27% of the subjects at 2 years and 5 years following LT, respectively. Subjects with rPSC were younger at LT (12.9 vs. 16.2 years), had faster progression from PSC diagnosis to LT (2.5 vs. 4.1 years), and had higher alanine aminotransferase (112 vs. 66 IU/L) at LT (all P < 0.01). Inflammatory bowel disease was more prevalent in the rPSC group (86% vs. 66%; P = 0.025). After LT, rPSC subjects had more episodes of biopsy-proved acute rejection (mean 3 vs. 1; P < 0.001), and higher prevalence of steroid-refractory rejection (41% vs. 20%; P = 0.04). In those with rPSC, 43% developed complications of portal hypertension, were relisted for LT, or died within 2 years of the diagnosis. Mortality was higher in the rPSC group (11.1% vs. 2.9%; P = 0.05). CONCLUSIONS The incidence of rPSC in this cohort was higher than previously reported, and was associated with increased morbidity and mortality. Patients with rPSC appeared to have a more aggressive, immune-reactive phenotype. These findings underscore the need to understand the immune mechanisms of rPSC, to lay the foundation for developing new therapies and improve outcomes in this challenging population.
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Affiliation(s)
| | | | | | - Cara L Mack
- University of Colorado School of Medicine, Aurora, CO
| | | | - Annemarie Broderick
- Children’s Health Ireland at Crumlin & University College Dublin, Dublin, Ireland
| | | | | | - Katryn N. Furuya
- Mayo Clinic, Rochester, MN and Medical College of Wisconsin, Milwaukee, WI
| | - Nitika Gupta
- Emory University School of Medicine, Atlanta, GA
| | | | - Maureen M Jonas
- Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | | | - Nanda Kerkar
- University of Rochester Medical Center, Rochester, NY
| | | | - Kaija-Leena Kolho
- University of Helsinki Hospital and Tampere University, Helsinki, Finland
| | - Bart GP Koot
- Amsterdam University Medical Center Amsterdam, The Netherlands
| | - Trevor J Laborda
- University of Utah and Intermountain Primary Children’s Hospital, Salt Lake City, UT
| | | | | | | | | | | | - Nadia Ovchinsky
- Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | | | | | - Kathleen B Schwarz
- University of California San Diego, San Diego, CA and Johns Hopkins University, Baltimore, MD
| | | | | | | | | | | | - Marek Woynarowski
- Faculty of Medicine and Health Sciences, UJK Kielce, Poland (former IP CZD Warsaw)
| | | | - Mark R. Deneau
- University of Utah and Intermountain Primary Children’s Hospital, Salt Lake City, UT
| | - Mark R. Deneau
- Department of Pediatrics University of Utah and Intermountain Primary Children’s Hospital Salt Lake City UT
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6
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Jonas MM, Rhee S, Kelly DA, Del Valle‐Segarra A, Feiterna‐Sperling C, Gilmour S, Gonzalez‐Peralta RP, Hierro L, Leung DH, Ling SC, Lobzin Y, Lobritto S, Mizuochi T, Narkewicz MR, Sabharwal V, Wen J, Kei Lon H, Marcinak J, Topp A, Tripathi R, Sokal E. Pharmacokinetics, Safety, and Efficacy of Glecaprevir/Pibrentasvir in Children With Chronic HCV: Part 2 of the DORA Study. Hepatology 2021; 74:19-27. [PMID: 33811356 PMCID: PMC8548879 DOI: 10.1002/hep.31841] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 12/07/2020] [Revised: 02/25/2021] [Accepted: 03/22/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIMS Glecaprevir/pibrentasvir (GLE/PIB) has shown high efficacy and safety in chronic HCV-infected adults and adolescents; data in children were limited. DORA part 2 is a phase 2/3, nonrandomized, open-label study evaluating the pharmacokinetics, efficacy, and safety of a pediatric formulation of GLE and PIB in children ages 3 to < 12 years. APPROACH AND RESULTS Children with chronic HCV infection, genotype 1-6, with or without compensated cirrhosis, were divided into three cohorts by age-cohort 2 (9 to < 12 years), cohort 3 (6 to < 9 years), and cohort 4 (3 to < 6 years)-and given weight-based doses of GLE and PIB for 8, 12, or 16 weeks. Primary endpoints were sustained virologic response at posttreatment week 12 (SVR12) and steady-state exposure; secondary endpoints were rates of persistent viremia, relapse, and reinfection. Safety and laboratory abnormalities were assessed. Final pediatric dosages determined to be efficacious were 250 mg GLE + 100 mg PIB (in children weighing ≥ 30 to < 45 kg), 200 mg GLE + 80 mg PIB (≥ 20 to < 30 kg), and 150 mg GLE + 60 mg PIB (12 to < 20 kg). Of 80 participants enrolled and dosed, 96% (77/80) achieved SVR12. One participant, on the initial dose ratio, relapsed by posttreatment week 4; no participants had virologic failures on the final dose ratio of GLE 50 mg/PIB 20 mg. Two nonresponders prematurely discontinued the study. Most adverse events (AEs) were mild; no drug-related serious AEs occurred. Pharmacokinetic exposures were comparable to those of adults. CONCLUSIONS A pediatric formulation of GLE/PIB was highly efficacious and well tolerated in chronic HCV-infected children 3 to < 12 years old.
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Affiliation(s)
- Maureen M. Jonas
- Division of Gastroenterology, Hepatology, and NutritionBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
| | | | - Deirdre A. Kelly
- The Liver UnitBirmingham Women’s & Children’s Hospital and University of BirminghamBirminghamUnited Kingdom
| | | | - Cornelia Feiterna‐Sperling
- Department of Pediatric Pulmonology, Immunology, and Intensive Care MedicineCharité–Universitätsmedizin BerlinBerlinGermany
| | - Susan Gilmour
- Stollery Children’s Hospital and University of AlbertaEdmontonABCanada
| | | | | | - Daniel H. Leung
- Division of Gastroenterology, Hepatology, and NutritionTexas Children’s HospitalHoustonTX
- Department of PediatricsBaylor College of MedicineHoustonTX
| | - Simon C. Ling
- Division of Gastroenterology, Hepatology, and NutritionThe Hospital for Sick ChildrenTorontoONCanada
- Department of PaediatricsUniversity of TorontoTorontoONCanada
| | - Yuri Lobzin
- Pediatric Research and Clinical Center for Infectious Diseases and North‐Western State Medical University named after I.I. MechnikovRussian FederationSt. PetersburgRussia
| | - Steven Lobritto
- Morgan Stanley Children’s Hospital of New YorkColumbia University Irving Medical CenterNew YorkNY
| | - Tatsuki Mizuochi
- Department of Pediatrics and Child HealthKurume University School of MedicineKurumeJapan
| | - Michael R. Narkewicz
- Digestive Health InstituteChildren’s Hospital ColoradoSection of Pediatric GastroenterologyHepatology, and NutritionDepartment of Pediatrics University of Colorado School of MedicineAuroraCO
| | - Vishakha Sabharwal
- Division of Pediatric Infectious DiseasesDepartment of PediatricsBoston University Medical CenterBostonMA
| | - Jessica Wen
- The Children’s Hospital Philadelphia and University of PennsylvaniaPhiladelphiaPA
| | | | | | | | | | - Etienne Sokal
- Division of Pediatric Gastroenterology and HepatologyUniversité Catholique de LouvainCliniques Universitaires Saint LucBrusselsBelgium
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Fahmy DM, Shokeir M, El Zeiny SM, Jonas MM, Abdallah A. Changes in Liver Stiffness and Noninvasive Fibrosis Scores in Egyptian Adolescents Successfully Treated with Ledipasvir-Sofosbuvir for Chronic Hepatitis C Virus Infection. J Pediatr 2021; 231:110-116. [PMID: 33347957 DOI: 10.1016/j.jpeds.2020.12.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 10/26/2020] [Revised: 11/22/2020] [Accepted: 12/14/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess changes in noninvasive liver fibrosis measurements after chronic hepatitis C eradication by direct-acting antivirals in Egyptian adolescents. STUDY DESIGN Liver stiffness measurement (LSM), by vibration-controlled transient elastography and noninvasive fibrosis scores (Firbosis-4, aspartate aminotransferase-platelet ratio index), was obtained before and 12 months after eradication with ledipasvir-sofosbuvir. The primary outcome was a more than 30% decrease in LSM with resulting fibrosis stage regression for initial fibrosis of F2 or higher and nonprogression of F0-F1, using the Ishak score (F0-F6). The secondary outcome was change in noninvasive fibrosis scores after treatment. RESULTS Analyzing 85 patients, the median baseline LSM was 5.8 (IQR, 4.2-6.5) and at follow-up 5.1 kPa (IQR, 4-6 kPa) (P = .045); 62 (73%) met the primary outcome, 16 patients (19%) experienced regression, and 46 (54%) nonprogression of LSM. Of 18 with initial fibrosis of F2 0r higher, 13 regressed to F0-F1 and 2 from F6 to F5, 1 unchanged at F3, and 1 increased to F3 and 1 to F4. Among 67 patients with a baseline fibrosis of F0-F1, 62 were unchanged and 5 increased-4 to F2 and 1 to F3. Although 23 (27%) had a more than 30% LSM increase, only 7 (8%), with associated comorbidities (4 β-thalassemia, 3 hepatic steatosis), had increased fibrosis stage. The median baseline FIB-4 and aspartate aminotransferase-platelet ratio index scores were 0.34 (IQR, 0.22-0.47) and 0.35 (0.24-0.57), and at follow-up 0.3 (IQR, 0.22-0.34) and 0.2 (0.18-2.8) (P < .001, <.001), respectively. CONCLUSIONS Chronic hepatitis C eradication by direct-acting antiviral agents in Egyptian adolescents was associated with nonprogression or regression of liver fibrosis, by noninvasive fibrosis measurements, at 12 months after treatment in the majority of cases.
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Affiliation(s)
- Doaa M Fahmy
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Mohamed Shokeir
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Sherine M El Zeiny
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Ahmed Abdallah
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Affiliation(s)
- Catherine A Chappell
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
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Azova S, Rajabi F, Modi BP, Mansfield L, Jonas MM, Drobysheva A, Boyd TK, Wassner AJ, Smith JR. Graves' disease in a five-month-old boy with an unusual treatment course. J Pediatr Endocrinol Metab 2021; 34:401-406. [PMID: 33675208 PMCID: PMC10653980 DOI: 10.1515/jpem-2020-0549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 09/22/2020] [Accepted: 11/05/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Graves' disease (GD) is rare in children under age five years. Antithyroid drugs are typically first-line therapy but carry the risks of agranulocytosis and liver dysfunction. CASE PRESENTATION A male infant with multiple congenital anomalies, left ventricular hypertrophy, and neurologic dysfunction developed GD at five months of life. The presence of chronic hepatitis complicated medical management. Potassium iodide was effective temporarily, but urgent thyroidectomy was required at nine months of age. Postoperatively, the patient developed a thyroid function pattern consistent with impaired pituitary sensitivity to thyroid hormone (TH) that responded to the addition of liothyronine. Exome sequencing revealed a heterozygous de novo duplication of the ATAD3 gene cluster, suggesting a possible mitochondrial disorder. CONCLUSIONS This case describes the youngest child to date to be diagnosed with endogenous GD and to successfully undergo definitive treatment with thyroidectomy. An underlying defect in mitochondrial function is suspected, suggesting a potential novel pathophysiologic link to early-onset thyroid autoimmunity. Additionally, this case illustrated the development of impaired pituitary sensitivity to TH following thyrotoxicosis of postnatal onset, which may contribute to our understanding of hypothalamic-pituitary-thyroid (HPT) axis development.
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Affiliation(s)
- Svetlana Azova
- Division of Endocrinology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Farrah Rajabi
- Division of Genetics and Genomics, Boston Children’s Hospital, Boston, MA, USA; and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Biren P. Modi
- Department of Surgery, Boston Children’s Hospital, Boston, MA, USA; and Thyroid Center, Boston Children’s Hospital, Boston, MA, USA
| | - Laura Mansfield
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA; and Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA
| | - Maureen M. Jonas
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA; and Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA, USA
| | - Anastasia Drobysheva
- Department of Pathology, British Columbia Children’s Hospital, Vancouver, BC, Canada
| | - Theonia K. Boyd
- Department of Pathology, Texas Children’s Hospital, Houston, TX, USA
| | - Ari J. Wassner
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA; and Thyroid Center, Boston Children’s Hospital, Boston, MA, USA
| | - Jessica R. Smith
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA; and Thyroid Center, Boston Children’s Hospital, Boston, MA, USA
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Deneau MR, Mack C, Perito ER, Ricciuto A, Valentino PL, Amin M, Amir AZ, Aumar M, Auth M, Broderick A, DiGuglielmo M, Draijer LG, Tavares Fagundes ED, El-Matary W, Ferrari F, Furuya KN, Gupta N, Hochberg JT, Homan M, Horslen S, Iorio R, Jensen MK, Jonas MM, Kamath BM, Kerkar N, Kim KM, Kolho KL, Koot BGP, Laborda TJ, Lee CK, Loomes KM, Martinez M, Miethke A, Miloh T, Mogul D, Mohammad S, Mohan P, Moroz S, Ovchinsky N, Palle S, Papadopoulou A, Rao G, Rodrigues Ferreira A, Sathya P, Schwarz KB, Shah U, Shteyer E, Singh R, Smolka V, Soufi N, Tanaka A, Varier R, Vitola B, Woynarowski M, Zerofsky M, Zizzo A, Guthery SL. The Sclerosing Cholangitis Outcomes in Pediatrics (SCOPE) Index: A Prognostic Tool for Children. Hepatology 2021; 73:1074-1087. [PMID: 32464706 PMCID: PMC8557635 DOI: 10.1002/hep.31393] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/21/2020] [Accepted: 05/03/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Disease progression in children with primary sclerosing cholangitis (PSC) is variable. Prognostic and risk-stratification tools exist for adult-onset PSC, but not for children. We aimed to create a tool that accounts for the biochemical and phenotypic features and early disease stage of pediatric PSC. APPROACH AND RESULTS We used retrospective data from the Pediatric PSC Consortium. The training cohort contained 1,012 patients from 40 centers. We generated a multivariate risk index (Sclerosing Cholangitis Outcomes in Pediatrics [SCOPE] index) that contained total bilirubin, albumin, platelet count, gamma glutamyltransferase, and cholangiography to predict a primary outcome of liver transplantation or death (TD) and a broader secondary outcome that included portal hypertensive, biliary, and cancer complications termed hepatobiliary complications (HBCs). The model stratified patients as low, medium, or high risk based on progression to TD at rates of <1%, 3%, and 9% annually and to HBCs at rates of 2%, 6%, and 13% annually, respectively (P < 0.001). C-statistics to discriminate outcomes at 1 and 5 years were 0.95 and 0.82 for TD and 0.80 and 0.76 for HBCs, respectively. Baseline hepatic fibrosis stage was worse with increasing risk score, with extensive fibrosis in 8% of the lowest versus 100% with the highest risk index (P < 0.001). The model was validated in 240 children from 11 additional centers and performed well. CONCLUSIONS The SCOPE index is a pediatric-specific prognostic tool for PSC. It uses routinely obtained, objective data to predict a complicated clinical course. It correlates strongly with biopsy-proven liver fibrosis. SCOPE can be used with families for shared decision making on clinical care based on a patient's individual risk, and to account for variable disease progression when designing future clinical trials.
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Affiliation(s)
- Mark R Deneau
- University of Utah and Intermountain Primary Children's HospitalSalt Lake CityUT
| | - Cara Mack
- University of Colorado School of MedicineAuroraCO
| | | | | | | | | | - Achiya Z Amir
- The Dana-Dwek Children's HospitalThe Tel-Aviv Medical CenterTel-Aviv UniversityTel AvivIsrael
| | | | - Marcus Auth
- Alder Hey Children's HospitalLiverpoolUnited Kingdom
| | - Annemarie Broderick
- Children's Health Ireland at Crumlin & University College DublinDublinIreland
| | | | | | | | | | | | - Katryn N Furuya
- University of Wisconsin-Madison School of Medicine and Public HealthMadisonWI
| | | | | | | | | | | | - M Kyle Jensen
- University of Utah and Intermountain Primary Children's HospitalSalt Lake CityUT
| | - Maureen M Jonas
- Boston Children's Hospital and Harvard Medical SchoolBostonMA
| | | | - Nanda Kerkar
- University of Rochester Medical CenterRochesterNY
| | | | - Kaija-Leena Kolho
- University of Helsinki Hospital and Tampere UniversityHelsinkiFinland
| | - Bart G P Koot
- Amsterdam University Medical CenterAmsterdamThe Netherlands
| | - Trevor J Laborda
- University of Utah and Intermountain Primary Children's HospitalSalt Lake CityUT
| | - Christine K Lee
- Boston Children's Hospital and Harvard Medical SchoolBostonMA
| | | | | | | | | | | | | | | | - Stacy Moroz
- University of Southern CaliforniaLos AngelesCA
| | - Nadia Ovchinsky
- Children's Hospital at MontefioreAlbert Einstein College of MedicineBronxNY
| | | | - Alexandra Papadopoulou
- First Department of PediatricsUniversity of AthensChildren's Hospital Agia SofiaAthensGreece
| | | | | | | | - Kathleen B Schwarz
- Johns Hopkins UniversityBaltimoreMD.,University of California San DiegoSan DiegoCA
| | - Uzma Shah
- Massachusetts General Hospital, Harvard Medical SchoolBostonMA
| | | | - Ruchi Singh
- Cincinnati Children's Hospital Medical CenterCincinnatiOH
| | | | | | | | - Raghu Varier
- Northwest Pediatric Gastroenterology LLCPortlandOR
| | | | | | | | - Andréanne Zizzo
- London Health Sciences CenterWestern UniversityLondonOntarioCanada
| | - Stephen L Guthery
- University of Utah and Intermountain Primary Children's HospitalSalt Lake CityUT
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11
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Deneau MR, Mack C, Mogul D, Perito ER, Valentino PL, Amir AZ, DiGuglielmo M, Draijer LG, El-Matary W, Furuya KN, Gupta N, Hochberg JT, Horslen S, Jensen MK, Jonas MM, Kerkar N, Koot BGP, Laborda TJ, Lee CK, Loomes KM, Martinez M, Miethke A, Miloh T, Mohammad S, Ovchinsky N, Rao G, Ricciuto A, Sathya P, Schwarz KB, Shah U, Singh R, Vitola B, Zizzo A, Guthery SL. Oral Vancomycin, Ursodeoxycholic Acid, or No Therapy for Pediatric Primary Sclerosing Cholangitis: A Matched Analysis. Hepatology 2021; 73:1061-1073. [PMID: 32946600 PMCID: PMC8557636 DOI: 10.1002/hep.31560] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/21/2020] [Accepted: 08/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Many children with primary sclerosing cholangitis (PSC) receive oral vancomycin therapy (OVT) or ursodeoxycholic acid (UDCA). There is a paucity of data on whether these medications improve outcomes. APPROACH AND RESULTS We analyzed retrospective data from the Pediatric PSC Consortium. Children treated with OVT were matched 1:1:1 to those treated with UDCA or managed with observation (no treatment) based on the closest propensity score, ensuring similar baseline characteristics. Two hundred sixty-four patients (88 each with OVT, UDCA, or observation) had matching propensity scores and were similar in demographics, phenotype, immunosuppression, baseline biochemistry, and hepatic fibrosis. After 1 year in an intention-to-treat analysis, all outcome metrics were similar regardless of treatment group. In OVT, UDCA, and untreated groups, respectively: Gamma-glutamyltransferase normalized in 53%, 49%, and 52% (P = not significant [NS]), liver fibrosis stage was improved in 20%, 13%, and 18% and worsened in 11%, 29%, and 18% (P = NS), and the 5-year probability of liver transplant listing was 21%, 10%, and 12% (P = NS). Favorable outcome was associated with having a mild phenotype of PSC and minimal hepatic fibrosis. CONCLUSIONS We presented the largest-ever description of outcomes on OVT in PSC and compared them to carefully matched patients on UDCA or no therapy. Neither OVT nor UDCA showed improvement in outcomes compared to a strategy of observation. Patients progressed to end-stage liver disease at similar rates. Spontaneous normalization of biochemistry is common in children receiving no therapy, particularly in the majority of children with a mild phenotype and an early stage of disease. Placebo-controlled treatment trials are needed to identify effective treatments for pediatric PSC.
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Affiliation(s)
- Mark R Deneau
- University of Utah and Intermountain Primary Children's HospitalSalt Lake CityUT
| | - Cara Mack
- University of Colorado School of MedicineAuroraCO
| | | | | | | | - Achiya Z Amir
- The Dana-Dwek Children's HospitalThe Tel-Aviv Medical CenterTel-Aviv UniversityTel AvivIsrael
| | | | | | | | - Katryn N Furuya
- Mayo ClinicRochesterMN.,University of Wisconsin-Madison School of Medicine and Public HealthMadisonWI
| | | | | | | | - M Kyle Jensen
- University of Utah and Intermountain Primary Children's HospitalSalt Lake CityUT
| | - Maureen M Jonas
- Boston Children's Hospital and Harvard Medical SchoolBostonMA
| | - Nanda Kerkar
- University of Rochester Medical CenterRochesterNY
| | - Bart G P Koot
- Amsterdam University Medical CenterAmsterdamThe Netherlands
| | - Trevor J Laborda
- University of Utah and Intermountain Primary Children's HospitalSalt Lake CityUT
| | - Christine K Lee
- Boston Children's Hospital and Harvard Medical SchoolBostonMA
| | | | | | | | | | | | - Nadia Ovchinsky
- Children's Hospital at MontefioreAlbert Einstein College of MedicineBronxNY
| | | | | | - Pushpa Sathya
- Memorial UniversitySt. John'sNewfoundland and LabradorCanada
| | - Kathleen B Schwarz
- Johns Hopkins UniversityBaltimoreMD.,University of California San DiegoSan DiegoCA
| | - Uzma Shah
- Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Ruchi Singh
- Cincinnati Children's Hospital Medical CenterCincinnatiOH
| | | | - Andréanne Zizzo
- London Health Sciences CenterWestern UniversityLondonOntarioCanada
| | - Stephen L Guthery
- University of Utah and Intermountain Primary Children's HospitalSalt Lake CityUT
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12
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Lee CK, Nastasio S, Mitchell PD, Fawaz R, Elisofon SA, Vakili K, Kim HB, Nguyen D, Jonas MM. Transient elastography assessment of liver allograft fibrosis in pediatric transplant recipients. Pediatr Transplant 2020; 24:e13736. [PMID: 32432836 DOI: 10.1111/petr.13736] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 09/20/2019] [Revised: 02/12/2020] [Accepted: 04/17/2020] [Indexed: 01/06/2023]
Abstract
TE measures liver stiffness to assess fibrosis. Its use in post-transplant patients was reported in few small pediatric studies. We evaluated TE ability to predict liver graft fibrosis in a large cohort while comparing it to the performance of APRI and FIB-4. We also investigated the effect of graft type on LSMs. Patients at Boston Children's Hospital who underwent LT and LSM ≤ 1 year from biopsy (2007-2018) were eligible. Ninety-four patients (45%M) aged 1-21 years (89% < 18 years; 13% < 2 years) were eligible. Median time between transplant/biopsy and LSM was 5.1 years and 52 days, respectively. Thirty-nine percent received whole-liver grafts, 54% TV grafts, and 6% as part of MV. At LSM, median ALT was 25 [IQR 16-33] IU/L. Twenty-one percent had METAVIR ≥ F2. LSM was statistically higher among those with significant fibrosis (METAVIR ≥ F2) compared to those with METAVIR F0/F1 (median [IQR] 7.5 [4.6, 13.6] vs 5.1 [4.0, 6.4] kPa, respectively) (P = .005 by Wilcoxon rank-sum test). APRI and FIB-4 distributions were not different across METAVIR stages. The AUROC for LSM was 0.71 (95% CI 0.56-0.85) with an optimal cut-point of 6.5 kPa. Graft type had no influence on the AUROC for LSM. TE is useful for assessing significant graft fibrosis in children and young adult LT recipients and performs better than APRI and FIB-4. TV grafts demonstrate similar correlation with histology as whole-liver grafts.
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Affiliation(s)
- Christine K Lee
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Silvia Nastasio
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Paul D Mitchell
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
| | - Rima Fawaz
- Section of Gastroenterology and Hepatology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Scott A Elisofon
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Khashayar Vakili
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Denis Nguyen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
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13
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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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14
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Ibrahim SH, Jonas MM, Taylor SA, Sanchez LHG, Wolf JL, Sundaram SS. Liver Diseases in the Perinatal Period: Interactions Between Mother and Infant. Hepatology 2020; 71:1474-1485. [PMID: 31925801 PMCID: PMC7150638 DOI: 10.1002/hep.31109] [Citation(s) in RCA: 12] [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: 08/28/2019] [Accepted: 12/19/2019] [Indexed: 12/19/2022]
Abstract
Liver diseases affecting the mother and infant dyad may present in the perinatal period from 20 weeks of gestation to 28 days of life. This review will focus on the current approach to neonatal acute liver failure and the progress made in the diagnosis and management of gestational alloimmune liver disease. It will highlight mother-to-child transmission of viral hepatitis, both management and public health implications. Emerging concepts implicating maternal obesity and nutrition in the development of a rapidly progressive nonalcoholic steatohepatitis phenotype in the offspring will be discussed. Finally, the presentation and management of acute fatty liver of pregnancy and intrahepatic cholestasis of pregnancy, and their impact on the fetus, will be reviewed.
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Affiliation(s)
- Samar H. Ibrahim
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Maureen M. Jonas
- Division of Pediatric Gastroenterology and Hepatology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah A. Taylor
- Division of Pediatric Gastroenterology and Hepatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, Illinois
| | | | - Jaqueline L. Wolf
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shikha S. Sundaram
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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15
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Jonas MM, Squires RH, Rhee SM, Lin C, Bessho K, Feiterna‐Sperling C, Hierro L, Kelly D, Ling SC, Strokova T, del Valle‐Segarra A, Lovell S, Liu W, Ng TI, Porcalla A, Gonzalez YS, Burroughs M, Sokal E. Pharmacokinetics, Safety, and Efficacy of Glecaprevir/Pibrentasvir in Adolescents With Chronic Hepatitis C Virus: Part 1 of the DORA Study. Hepatology 2020; 71:456-462. [PMID: 31254392 PMCID: PMC7028097 DOI: 10.1002/hep.30840] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [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] [Received: 04/18/2019] [Accepted: 06/25/2019] [Indexed: 12/21/2022]
Abstract
The pangenotypic regimen of glecaprevir and pibrentasvir (G/P) is approved to treat adults with chronic hepatitis C virus (HCV) infection and has yielded high cure rates in adults in clinical trials. Approved treatment options for pediatrics may include ribavirin. A pangenotypic regimen for pediatric patients remains an unmet need. DORA is an ongoing phase 2/3, nonrandomized, open-label study evaluating the pharmacokinetics (PK), safety, and efficacy of G/P in pediatric patients with chronic HCV. This analysis includes Part 1 of the study, conducted in adolescent patients 12-17 years of age given the adult regimen of G/P (300 mg/120 mg) once daily for 8-16 weeks according to the indication durations used in adults. Patients were either treatment naïve or experienced with interferon-based regimens. The primary PK endpoint was steady-state exposures for glecaprevir and pibrentasvir; the primary efficacy endpoint was sustained virologic response 12 weeks after treatment (SVR12). The secondary efficacy endpoints were on-treatment virologic failure, relapse, and reinfection. Safety and tolerability were monitored. Part 1 enrolled 48 adolescent patients infected with genotypes 1, 2, 3, or 4, of whom 47 were administered G/P. All 47 patients (100%) achieved SVR12. No on-treatment virologic failures or relapses occurred. PK exposures of glecaprevir and pibrentasvir were comparable to exposures in adults. No adverse events (AEs) led to treatment discontinuation, and no serious AEs occurred. Conclusion: Adolescent patients with chronic HCV infection treated with G/P achieved a comparable exposure to adults, 100% SVR12 rate, and safety profile consistent with that in adults. This pangenotypic regimen demonstrated 100% efficacy within the adolescent population in as little as 8 weeks of treatment.
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Affiliation(s)
- Maureen M. Jonas
- Division of Gastroenterology, Hepatology, and NutritionBoston Children's HospitalBostonMA,Department of PediatricsHarvard Medical SchoolBostonMA
| | - Robert H. Squires
- Division of Gastroenterology, Hepatology, and NutritionUPMC Children's Hospital of PittsburghPittsburghPA,Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPA
| | | | | | | | | | | | - Deirdre Kelly
- Birmingham Women's & Children's HospitalBirminghamUnited Kingdom
| | - Simon C. Ling
- Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children, and Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Tatiana Strokova
- Federal Research Centre of Nutrition and BiotechnologyMoscowRussian Federation
| | | | | | | | | | | | | | | | - Etienne Sokal
- Cliniques Universitaires Saint‐LucUniversité Catholique de LouvainBrusselsBelgium
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16
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Rosenthal P, Schwarz KB, Gonzalez‐Peralta RP, Lin C, Kelly DA, Nightingale S, Balistreri WF, Bansal S, Jonas MM, Massetto B, Brainard DM, Hsueh C, Shao J, Parhy B, Davison S, Feiterna‐Sperling C, Gillis LA, Indolfi G, Sokal EM, Murray KF, Wirth S. Sofosbuvir and Ribavirin Therapy for Children Aged 3 to <12 Years With Hepatitis C Virus Genotype 2 or 3 Infection. Hepatology 2020; 71:31-43. [PMID: 31222783 PMCID: PMC7004103 DOI: 10.1002/hep.30821] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [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: 02/19/2019] [Accepted: 06/14/2019] [Indexed: 12/11/2022]
Abstract
Currently, the only approved hepatitis C virus (HCV) treatment for children aged <12 years is pegylated interferon plus ribavirin. In an open-label study, we evaluated the safety and efficacy of sofosbuvir plus ribavirin for 12 weeks in children aged 3 to <12 years chronically infected with genotype 2 or for 24 weeks in patients with genotype 3. Patients aged 3 to <6 years weighing <17 kg received sofosbuvir 150 mg, and patients aged 3 to <6 years weighing ≥17 kg and all patients aged 6 to <12 years received sofosbuvir 200 mg once daily. Intensive pharmacokinetic sampling conducted in each age group confirmed the appropriateness of sofosbuvir doses. For all patients, ribavirin dosing was determined by baseline weight (up to 1,400 mg/day, two divided doses). The primary efficacy endpoint was sustained virologic response 12 weeks after therapy (SVR12). Fifty-four patients were enrolled (41 aged 6 to <12 years and 13 aged 3 to <6 years). Most were treatment naïve (98%) and infected perinatally (94%). All but one patient achieved SVR12 (53/54, 98%; 95% confidence interval, 90%-100%). The patient who did not achieve SVR12 was a 4-year-old who discontinued treatment after 3 days because of "abnormal drug taste." The most commonly reported adverse events in patients aged 6 to <12 years were vomiting (32%) and headache (29%), and those in patients aged 3 to <6 years were vomiting (46%) and diarrhea (39%). One 3-year-old patient had a serious adverse event of accidental ribavirin overdose requiring hospitalization for monitoring; this patient completed treatment and achieved SVR12. Conclusion: Sofosbuvir plus ribavirin was well tolerated and highly effective in children aged 3 to <12 years with chronic HCV genotype 2 or 3 infection.
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Affiliation(s)
| | | | | | | | | | - Scott Nightingale
- University of Newcastle and John Hunter Children’s HospitalAustralia
| | | | | | | | | | | | | | | | | | | | | | | | | | - Etienne M. Sokal
- Cliniques Universitaires St. Luc, Université Catholique de LouvainBrusselsBelgium
| | - Karen F. Murray
- University of Washington School of Medicine and Seattle Children’s HospitalSeattleWA
| | - Stefan Wirth
- Helios Medical CenterWitten/Herdecke UniversityWuppertalGermany
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17
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Jhaveri R, Broder T, Bhattacharya D, Peters MG, Kim AY, Jonas MM. Universal Screening of Pregnant Women for Hepatitis C: The Time Is Now. Clin Infect Dis 2019; 67:1493-1497. [PMID: 30215670 DOI: 10.1093/cid/ciy586] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/13/2018] [Indexed: 01/01/2023] Open
Abstract
The epidemiology of hepatitis C virus (HCV) has changed significantly over the last decade. Once most prevalent among older adults, the current burden has disproportionately affected young adults including women of childbearing age (WOCA). The Society for Maternal-Fetal Medicine recently issued guidelines that made no change in the recommendation to screen pregnant women based on risk factors. The current burden in young adults including WOCA supports a change in strategy away from risk-based screening to universal HCV screening in pregnancy. Universal screening offers several advantages that position us for a future where HCV treatment in pregnancy can happen and offers us progress toward the elimination of HCV.
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Affiliation(s)
- Ravi Jhaveri
- Division of Pediatric Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine
| | - Tina Broder
- National Viral Hepatitis Roundtable, Washington, D.C
| | - Debika Bhattacharya
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Marion G Peters
- Division of Gastroenterology, Department of Medicine, School of Medicine, University of California, San Francisco
| | - Arthur Y Kim
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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18
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Nastasio S, Jonas MM. Effect of Universal Infant Hepatitis B Virus Immunization on Mother-to-Child Hepatitis B Virus Transmission. J Infect Dis 2019; 220:1089-1090. [PMID: 30576508 DOI: 10.1093/infdis/jiy707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/05/2018] [Indexed: 01/15/2023] Open
Affiliation(s)
- Silvia Nastasio
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Massachusetts
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Massachusetts.,Center for Childhood Liver Disease, Boston Children's Hospital, Massachusetts
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19
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Indolfi G, Easterbrook P, Dusheiko G, Siberry G, Chang MH, Thorne C, Bulterys M, Chan PL, El-Sayed MH, Giaquinto C, Jonas MM, Meyers T, Walsh N, Wirth S, Penazzato M. Hepatitis B virus infection in children and adolescents. Lancet Gastroenterol Hepatol 2019; 4:466-476. [PMID: 30982722 DOI: 10.1016/s2468-1253(19)30042-1] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/20/2019] [Accepted: 01/22/2019] [Indexed: 02/06/2023]
Abstract
Hepatitis B virus (HBV) infection is a major cause of acute and chronic liver disease and associated morbidity and mortality worldwide. Vertical (mother-to-child) and horizontal early childhood transmission are the main routes of HBV transmission and are responsible for most chronic infections, including among adults who bear the greatest burden of morbidity and mortality. Universal hepatitis B immunisation at birth and in infancy is the key strategy for global elimination of HBV infection, and has been highly effective in reducing new vertical infections. However, global progress in scale-up of HBV testing and treatment has been slow in adults and children. In this Series paper, we summarise knowledge on the epidemiology, natural history, and treatment of chronic HBV infection in adolescents and children, and we highlight key differences from HBV infection in adults. The estimated global prevalence of HBV infection in children aged 5 years or younger is 1·3%. Most children are in the high-replication, low-inflammation phase of infection, with normal or only slightly raised aminotransferases; cirrhosis and hepatocellular carcinoma are rare. Although entecavir is approved and recommended for children aged 2-17 years, and tenofovir for those aged 12-18 years, a conservative approach to treatment initiation in children is recommended. Key actions to address current policy gaps include: validation of non-invasive tests for liver disease staging; additional immunopathogenesis studies in children with HBV infection; long-term follow-up of children on nucleoside or nucleotide analogue regimens to inform guidance on when to start treatment; evaluation of different treatment strategies for children with high rates of HBV replication; and establishment of paediatric treatment registries and international consortia to promote collaborative research.
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Affiliation(s)
- Giuseppe Indolfi
- Paediatric and Liver Unit, Meyer Children's University Hospital of Florence, Florence, Italy
| | - Philippa Easterbrook
- Global Hepatitis Programme and HIV Department, World Health Organization, Geneva, Switzerland.
| | - Geoffrey Dusheiko
- King's College Hospital, London, UK; University College London Medical School, London, UK
| | - George Siberry
- Office of the US Global AIDS Coordinator, US Department of State, Washington, DC, USA
| | - Mei-Hwei Chang
- Department of Paediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Claire Thorne
- UCL Great Ormond Street Institute of Child Health, University College London, NIHR GOSH BRC, London, UK
| | - Marc Bulterys
- Global Hepatitis Programme and HIV Department, World Health Organization, Geneva, Switzerland
| | - Po-Lin Chan
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | - Manal H El-Sayed
- Department of Paediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Carlo Giaquinto
- Department of Women and Child Health, University of Padova, Padova, Italy
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Tammy Meyers
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Nick Walsh
- Pan American Health Organization, World Health Organization Regional Office for the Americas, Washington, DC, USA
| | - Stefan Wirth
- Department of Paediatrics, Helios Medical Centre Wuppertal, Witten-Herdecke University, Witten, Germany
| | - Martina Penazzato
- Global Hepatitis Programme and HIV Department, World Health Organization, Geneva, Switzerland
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Indolfi G, Easterbrook P, Dusheiko G, El-Sayed MH, Jonas MM, Thorne C, Bulterys M, Siberry G, Walsh N, Chang MH, Meyers T, Giaquinto C, Wirth S, Chan PL, Penazzato M. Hepatitis C virus infection in children and adolescents. Lancet Gastroenterol Hepatol 2019; 4:477-487. [PMID: 30982721 DOI: 10.1016/s2468-1253(19)30046-9] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [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: 11/25/2018] [Revised: 01/20/2019] [Accepted: 01/22/2019] [Indexed: 02/06/2023]
Abstract
Hepatitis C virus (HCV) infection is a major cause of chronic liver disease and associated morbidity and mortality worldwide. Short-course, oral, curative, direct-acting antiviral regimens have transformed treatment for HCV infection. Since the 2016 launch of the first global strategy towards elimination of viral hepatitis as a public health threat by 2030, the predominant focus of the global response has been on the treatment of adults, who bear the greatest burden of morbidity and mortality of HCV-related chronic liver disease. Compared with adults, there has been little attention paid to addressing the response to HCV in children and adolescents, in part because of the scarcity of data to inform specific paediatric management practices and policy. In this Series paper, we summarise knowledge on the epidemiology, natural history, and treatment of chronic HCV infection in adolescents and children, and we highlight key differences from infection acquired in adulthood. The estimated global prevalence and burden of HCV infection in children aged 1-19 years is 0·15%, corresponding to 3·5 million people (95% CI 3·1-3·9 million). HCV infection is usually asymptomatic during childhood, and cirrhosis and hepatocellular carcinoma are rare. Sofosbuvir with ledipasvir and sofosbuvir with ribavirin have received regulatory approval and guidelines recommend their use in adolescents aged 12 years and older with HCV infection. In April, 2019, glecaprevir with pibrentasvir also received regulatory approval for adolescents aged 12-17 years. Key actions to address the current policy gaps and achieve treatment scale-up that is comparable to that in adults include: establishment of a campaign on access to testing and treatment that is targeted at children and adolescents; fast-track evaluation of pan-genotypic regimens; and accelerated approval of paediatric formulations. Research gaps that need to be addressed include: age-specific prevalence studies of HCV viraemia in priority countries; further validation of non-invasive tests for staging of liver disease in children; and establishment of paediatric treatment registries and international consortia to promote collaborative research agendas.
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Affiliation(s)
- Giuseppe Indolfi
- Paediatric and Liver Unit, Meyer Children's University Hospital of Florence, Florence, Italy
| | - Philippa Easterbrook
- Global Hepatitis Programme and HIV Department, World Health Organization, Geneva, Switzerland.
| | - Geoffrey Dusheiko
- King's College Hospital, London, UK; University College London Medical School, London, UK
| | - Manal H El-Sayed
- Department of Paediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Claire Thorne
- UCL Great Ormond Street Institute of Child Health, University College London, NIHR GOSH BRC, London, UK
| | - Marc Bulterys
- Global Hepatitis Programme and HIV Department, World Health Organization, Geneva, Switzerland
| | - George Siberry
- Office of the US Global AIDS Coordinator, US Department of State, Washington, DC, USA
| | - Nick Walsh
- Pan American Health Organization, World Health Organization Regional Office for the Americas, Washington, DC, USA
| | - Mei-Hwei Chang
- Department of Paediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Tammy Meyers
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Carlo Giaquinto
- Department of Women and Child Health, University of Padova, Padova, Italy
| | - Stefan Wirth
- Department of Paediatrics, Helios Medical Centre Wuppertal, Witten-Herdecke University, Witten, Germany
| | - Po-Lin Chan
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | - Martina Penazzato
- Global Hepatitis Programme and HIV Department, World Health Organization, Geneva, Switzerland
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21
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Murray KF, Balistreri WF, Bansal S, Whitworth S, Evans HM, Gonzalez-Peralta RP, Wen J, Massetto B, Kersey K, Shao J, Garrison KL, Parhy B, Brainard DM, Arnon R, Gillis LA, Jonas MM, Lin CH, Narkewicz MR, Schwarz K, Rosenthal P. Safety and Efficacy of Ledipasvir-Sofosbuvir With or Without Ribavirin for Chronic Hepatitis C in Children Ages 6-11. Hepatology 2018; 68:2158-2166. [PMID: 30070726 DOI: 10.1002/hep.30123] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
Currently, there are no interferon-free treatments available for hepatitis C virus (HCV)-infected patients younger than 12 years. We evaluated the safety and effectiveness of the all-oral regimen ledipasvir-sofosbuvir ± ribavirin in HCV-infected children aged 6 to <12 years. In an open-label study, patients aged 6 to <12 years received ledipasvir 45 mg-sofosbuvir 200 mg as two fixed-dose combination tablets 22.5/100 mg once daily, with or without ribavirin, for 12 or 24 weeks, depending on HCV genotype and cirrhosis status. The primary efficacy endpoint was sustained virologic response 12 weeks after therapy (SVR12). Twelve patients underwent intensive pharmacokinetic sampling to confirm the appropriateness of the ledipasvir and sofosbuvir dosages. Ninety-two patients were enrolled (88 genotype 1, 2 genotype 3, and 2 genotype 4), with a median age of 9 years (range, 6-11). Most were perinatally infected (97%) and treatment-naive (78%). Two were confirmed to have cirrhosis, while the degree of fibrosis was unknown in 55 patients. The overall SVR12 rate was 99% (91/92; 95% confidence interval, 94%-100%). The single patient not reaching SVR relapsed 4 weeks after completing 12 weeks of treatment. The most common adverse events were headache and pyrexia. One patient had three serious adverse events, which were considered to be not related to study treatment: tooth abscess, abdominal pain, and gastroenteritis. The area under the concentration-time curve and maximum concentration values for sofosbuvir, its primary metabolite GS-331007, and ledipasvir were within predefined pharmacokinetic equivalence boundaries (50%-200%) compared to values in adults in phase 2/3 of the ledipasvir and sofosbuvir studies. Conclusion: Ledipasvir-sofosbuvir was well tolerated and highly effective in children 6 to <12 years old with chronic HCV.
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Affiliation(s)
- Karen F Murray
- University of Washington and Seattle Children's Hospital, Seattle, WA
| | | | | | | | - Helen M Evans
- Auckland Clinical Studies and Starship Child Health, Auckland, New Zealand
| | | | - Jessica Wen
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | | | - Michael R Narkewicz
- University of Colorado, School of Medicine and Children's Hospital of Colorado, Aurora, CO
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22
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Bader RM, Jonas MM, Mitchell PD, Wiggins S, Lee CK. Controlled attenuation parameter: A measure of hepatic steatosis in patients with cystic fibrosis. J Cyst Fibros 2018; 18:280-285. [PMID: 30509601 DOI: 10.1016/j.jcf.2018.11.004] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/21/2018] [Accepted: 11/12/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hepatic steatosis is a common manifestation of CF-related liver disease(CFLD). Controlled attenuation parameter(CAP) measurement during transient elastography(TE) semiquantifies liver steatosis. We examined the relationship between CAP and CFLD severity, clinical factors and liver stiffness measurements(LSM). METHODS This is a cross-sectional study of CF patients seen for outpatient care between January 2013-March 2014. CFLD severity was categorized as no CFLD, CFLD without portal hypertension(PHTN) and CFLD with PHTN, based on published criteria. RESULTS 129 patients (median 18.4y; 57% male) had valid CAP. 70(54%) had no CFLD, 44(34%) CFLD without PHTN, and 15(12%) CFLD with PHTN. The median CAP was 210 dB/m (IQR 181-239). Steatosis(CAP ≥230 dB/m) was seen in 27% of subjects without CFLD, 48% in CFLD but no PHTN, and 20% in with CFLD and PHTN(P = .04). CAP was higher for subjects with CFLD without PHTN (P < .05). There was no CAP difference between subjects with no CFLD and those with CFLD and PHTN (P ≥ .65). LSM was not different between no CFLD and CFLD without PHTN (P = .07), but each of these groups had lower LSM compared to subjects with CFLD and PHTN(P < .001 for each). Except for direct bilirubin, CAP was not associated with clinical markers of liver disease. CONCLUSION CAP was normal in 86(67%) of patients with CF and was not associated with standard clinical markers of liver disease. CAP was higher in patients with liver disease, which could possibly reflect the loss of steatosis observed with progression to cirrhosis and portal hypertension.
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Affiliation(s)
- Razan M Bader
- Multi Organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | - Paul D Mitchell
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, United States
| | - Shanna Wiggins
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | - Christine K Lee
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, United States.
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23
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Leung DH, Wirth S, Yao BB, Viani RM, Gonzalez‐Peralta RP, Jonas MM, Lobritto SJ, Narkewicz MR, Sokal E, Fortuny C, Hsu EK, Del Valle‐Segarra A, Zha J, Larsen L, Liu L, Shuster DL, Cohen DE, Rosenthal P. Ombitasvir/Paritaprevir/Ritonavir With or Without Dasabuvir and With or Without Ribavirin for Adolescents With HCV Genotype 1 or 4. Hepatol Commun 2018; 2:1311-1319. [PMID: 30411078 PMCID: PMC6211326 DOI: 10.1002/hep4.1250] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 05/09/2018] [Accepted: 07/31/2018] [Indexed: 12/12/2022] Open
Abstract
In adults, treatment of hepatitis C virus (HCV) infection with ombitasvir (OBV)/paritaprevir (PTV)/ritonavir (r) with or without dasabuvir (DSV) and ±ribavirin (RBV) results in high rates of sustained virologic response (SVR). However, these regimens have not been investigated in adolescents. This ongoing, open-label, phase 2/3 study evaluated the pharmacokinetics, safety, and efficacy of OBV/PTV/r+DSV±RBV treatment for 12 weeks in adolescents infected with HCV genotype (GT) 1 without cirrhosis (part 1) and the safety and efficacy of OBV/PTV/r±DSV±RBV treatment for 12 or 24 weeks in adolescents infected with GT1 or GT4 without cirrhosis or with compensated cirrhosis (parts 1 and 2). Patients were 12-17 years of age and treatment naive or interferon experienced. Treatment regimens were based on HCV GT and cirrhosis status. Endpoints were SVR at posttreatment week 12 (SVR12), adverse events (AEs), and pharmacokinetic parameters. Thirty-eight adolescents were enrolled, 66% were female patients, and 76% were White; 42%, 40%, and 18% of patients had HCV GT1a, GT1b, and GT4 infections, respectively. Median age was 15 years (range, 12-17 years), and 1 patient had cirrhosis. The SVR12 rate was 100% (38/38; 95% confidence interval [CI], 90.8%-100%). No treatment-emergent grade 3 or 4 laboratory abnormalities were reported. No serious AEs occurred on treatment, and no AEs led to study drug discontinuation. The most common AEs were headache (21%), fatigue (18%), nasopharyngitis (13%), pruritus (13%), and upper respiratory tract infection (11%). Intensive pharmacokinetic results showed OBV, PTV, DSV, and ritonavir drug exposures were comparable to those seen in adults. Conclusion: Treatment with OBV/PTV/r±DSV±RBV was well tolerated and highly efficacious in adolescents with HCV GT1 or GT4 infection.
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Affiliation(s)
- Daniel H. Leung
- Division of Gastroenterology, Hepatology, and Nutrition, Texas Children’s Hospital and Department of PediatricsBaylor College of MedicineHoustonTX
| | - Stefan Wirth
- HELIOS Medical Center Wuppertal, Department of PediatricsWitten/Herdecke UniversityWuppertalGermany
| | | | - Rolando M. Viani
- AbbVie IncNorth ChicagoIL
- Present address:
University of California San DiegoSchool of MedicineSan DiegoCA
| | - Regino P. Gonzalez‐Peralta
- Department of PediatricsUniversity of Florida College of Medicine and Shands Children’s HospitalGainesvilleFL
- Present address:
Division of GastroenterologyHepatology and Liver TransplantationFlorida Hospital for ChildrenOrlandoFL
| | - Maureen M. Jonas
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital and Department of PediatricsHarvard Medical SchoolBostonMA
| | - Steven J. Lobritto
- New York‐Presbyterian Morgan Stanley Children’s HospitalDepartment of PediatricsColumbia University Medical CenterNew YorkNY
| | - Michael R. Narkewicz
- Digestive Health InstituteChildren’s Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of PediatricsUniversity of Colorado School of MedicineAuroraCO
| | - Etienne Sokal
- Cliniques Universitaires Saint‐Luc, Université Catholique de LouvainBrusselsBelgium
| | - Clàudia Fortuny
- Servei de PediatriaHospital Sant Joan de Déu y Universitat de BarcelonaBarcelonaSpain
| | - Evelyn K. Hsu
- Seattle Children’s Hospital and Department of PediatricsUniversity of Washington School of MedicineSeattleWA
| | | | | | | | - Li Liu
- AbbVie IncNorth ChicagoIL
| | - Diana L. Shuster
- AbbVie IncNorth ChicagoIL
- Present address:
PRA Health SciencesRaleighNC
| | | | - Philip Rosenthal
- Department of PediatricsUniversity of California San FranciscoSan FranciscoCA
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24
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Chung RT, Ghany MG, Kim AY, Marks KM, Naggie S, Vargas HE, Aronsohn AI, Bhattacharya D, Broder T, Falade-Nwulia OO, Fontana RJ, Gordon SC, Heller T, Holmberg SD, Jhaveri R, Jonas MM, Kiser JJ, Linas BP, Lo Re V, Morgan TR, Nahass RG, Peters MG, Reddy KR, Reynolds A, Scott JD, Searson G, Swan T, Terrault NA, Trooskin SB, Wong JB, Workowski KA. Hepatitis C Guidance 2018 Update: AASLD-IDSA Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection. Clin Infect Dis 2018; 67:1477-1492. [PMID: 30215672 PMCID: PMC7190892 DOI: 10.1093/cid/ciy585] [Citation(s) in RCA: 422] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 07/14/2018] [Indexed: 11/13/2022] Open
Abstract
Recognizing the importance of timely guidance regarding the rapidly evolving field of hepatitis C management, the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) developed a web-based process for the expeditious formulation and dissemination of evidence-based recommendations. Launched in 2014, the hepatitis C virus (HCV) guidance website undergoes periodic updates as necessitated by availability of new therapeutic agents and/or research data. A major update was released electronically in September 2017, prompted primarily by approval of new direct-acting antiviral agents and expansion of the guidance's scope. This update summarizes the latest release of the HCV guidance and focuses on new or amended recommendations since the previous September 2015 print publication. The recommendations herein were developed by volunteer hepatology and infectious disease experts representing AASLD and IDSA and have been peer reviewed and approved by each society's governing board.
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Terrault NA, Brown RS, Lok AS, Wong JB, Bzowej NH, Chang KM, Hwang JP, Jonas MM, McMahon BJ. Reply. Hepatology 2018; 68:1658-1660. [PMID: 30070717 DOI: 10.1002/hep.30137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 12/15/2017] [Revised: 04/22/2018] [Accepted: 05/20/2018] [Indexed: 01/15/2023]
Affiliation(s)
- Norah A Terrault
- Division of Gastroenterology/Hepatology, University of California San Francisco, San Francisco, CA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medica, l College, New York, NY
| | - Anna Sf Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - John B Wong
- Division of Clinical Decision Making, Tufts Medical Center, Tufts Unive, rsity School of Medicine, Boston, MA
| | | | - Kyong-Mi Chang
- Division of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jessica P Hwang
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Brian J McMahon
- Liver Diseases and Hepatitis Program, Alaska NativeTribal Health Consortium, Anchorage, AK
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26
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Lee CK, Mitchell PD, Raza R, Harney S, Wiggins SM, Jonas MM. Validation of Transient Elastography Cut Points to Assess Advanced Liver Fibrosis in Children and Young Adults: The Boston Children's Hospital Experience. J Pediatr 2018; 198:84-89.e2. [PMID: 29685617 PMCID: PMC6019197 DOI: 10.1016/j.jpeds.2018.02.062] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 01/30/2018] [Accepted: 02/27/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To derive an optimal liver stiffness measurement cut point to discriminate METAVIR fibrosis stage F4 and to validate both METAVIR fibrosis stage F3-F4 and F4 cut points in a separate cohort. STUDY DESIGN Patients at Boston Children's Hospital with liver stiffness measurement from 2006 to 2016 and liver biopsy ≤12 months before screening were eligible. Patients enrolled 2006-2011 were used to calibrate liver stiffness measurement cut points and those enrolled 2011-2016 for validation. Diagnostic performance was assessed by receiver operating curve analysis. RESULTS In total, 267 subjects were enrolled (97 calibration, 170 validation). The cohorts were similar with 54% male, aged 0-29 years (median 13 years), and liver diseases including 21% autoimmune, 19% viral, 11% nonalcoholic fatty liver, 9% cholestatic, and 9% primary sclerosing cholangitis. Cut points to discriminate F3-F4 and F4 were >8.6 kPa and >11.5 kPa with 81% and 84% accuracy, respectively. Applied to the validation cohort, accuracy was 67% and 75%, respectively. In 44 fasted subjects, the accuracy was 73% and 80%, respectively. CONCLUSION This study validates previously determined liver stiffness measurement cut points of 8.6 kPa and 11.5 kPa to predict METAVIR F3-F4 and F4 fibrosis in children and young adults in separate cohorts. With increasing data on the utility and validity of liver stiffness measurement in children, transient elastography may help identify patients with greater risk of advanced fibrosis and those who need liver biopsy assessment and/or surveillance for the complications of cirrhosis in a variety of liver disorders.
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Affiliation(s)
- Christine K. Lee
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Paul D. Mitchell
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA
| | - Roshan Raza
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Sarah Harney
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Shanna M. Wiggins
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Maureen M. Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
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Terrault NA, Lok ASF, McMahon BJ, Chang KM, Hwang JP, Jonas MM, Brown RS, Bzowej NH, Wong JB. Update on Prevention, Diagnosis, and Treatment of Chronic Hepatitis B: AASLD 2018 Hepatitis B Guidance. Clin Liver Dis (Hoboken) 2018; 12:33-34. [PMID: 30988907 PMCID: PMC6385899 DOI: 10.1002/cld.728] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [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: 05/14/2018] [Accepted: 05/14/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Norah A Terrault
- Division of Gastroenterology/Hepatology University of California San Francisco San Francisco CA
| | - Anna S F Lok
- Division of Gastroenterology and Hepatology University of Michigan Ann Arbor MI
| | - Brian J McMahon
- Liver Diseases and Hepatitis Program Alaska NativeTribal Health Consortium Anchorage AK
| | - Kyong-Mi Chang
- Division of Gastroenterology Corporal Michael J. Crescenz VA Medical Center & University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Jessica P Hwang
- Department of General Internal Medicine The University of Texas MD Anderson Cancer Center Houston TX
| | - Maureen M Jonas
- Division of Gastroenterology Hepatology and Nutrition, Boston Children's Hospital Boston MA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology Weill Cornell Medical College New York NY
| | | | - John B Wong
- Division of Clinical Decision Making, Tufts Medical Center Tufts University School of Medicine Boston MA
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28
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Terrault NA, Lok ASF, McMahon BJ, Chang KM, Hwang JP, Jonas MM, Brown RS, Bzowej NH, Wong JB. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology 2018; 67:1560-1599. [PMID: 29405329 PMCID: PMC5975958 DOI: 10.1002/hep.29800] [Citation(s) in RCA: 2247] [Impact Index Per Article: 374.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Norah A Terrault
- Division of Gastroenterology/Hepatology, University of California San Francisco, San Francisco, CA
| | - Anna S F Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Brian J McMahon
- Liver Diseases and Hepatitis Program, Alaska NativeTribal Health Consortium, Anchorage, AK
| | - Kyong-Mi Chang
- Division of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center & University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jessica P Hwang
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY
| | | | - John B Wong
- Division of Clinical Decision Making, Tufts Medical Center, Tufts University School of Medicine, Boston, MA
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29
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Wirth S, Rosenthal P, Gonzalez-Peralta RP, Jonas MM, Balistreri WF, Lin CH, Hardikar W, Kersey K, Massetto B, Kanwar B, Brainard DM, Shao J, Svarovskaia E, Kirby B, Arnon R, Murray KF, Schwarz KB. Sofosbuvir and ribavirin in adolescents 12-17 years old with hepatitis C virus genotype 2 or 3 infection. Hepatology 2017; 66:1102-1110. [PMID: 28543053 DOI: 10.1002/hep.29278] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/16/2017] [Accepted: 05/18/2017] [Indexed: 12/15/2022]
Abstract
UNLABELLED Children with chronic hepatitis C virus infection have limited treatment options. We evaluated the all-oral combination of sofosbuvir and ribavirin in adolescents aged 12-17 with hepatitis C virus genotype 2 or 3 (ClinicalTrials.gov NCT02175758). Fifty-two patients received sofosbuvir 400 mg once daily and weight-based ribavirin twice daily for 12 (genotype 2) or 24 (genotype 3) weeks. The pharmacokinetics of sofosbuvir and its metabolite GS-331007 were evaluated by intensive plasma sampling at day 7 in the first 10 patients enrolled and by sparse sampling in all patients throughout treatment. The primary efficacy endpoint was the percentage of patients with a sustained virologic response 12 weeks after treatment (SVR12). The median age of patients was 15 years, and 75% had genotype 3. Eighty-three percent of patients were treatment-naive, and 73% were infected by vertical transmission. Forty percent were assessed as not having cirrhosis; the remainder did not have a cirrhosis determination. Overall, SVR12 was achieved by 98% of patients (51/52; 95% confidence interval, 90%-100%). SVR12 rates were 100% (13/13) for patients with genotype 2 and 97% (38/39) for those with genotype 3. The single patient who did not achieve SVR12 was lost to follow-up after achieving SVR4. The most commonly reported adverse events were nausea (27%) and headache (23%). When compared with the exposure in adults treated in phase 2 and 3 sofosbuvir studies, the area under the curve and maximum concentration for sofosbuvir and GS-331007 in adolescents were within predefined pharmacokinetic equivalence boundaries of 50%-200%. CONCLUSION Sofosbuvir and ribavirin was safe and highly effective in adolescents with chronic hepatitis C virus genotype 2 or 3 infection. (Hepatology 2017;66:1102-1110).
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Affiliation(s)
- Stefan Wirth
- Helios Medical Center, Witten/Herdecke University, Wuppertal, Germany
| | | | | | | | | | | | - Winita Hardikar
- The Royal Children's Hospital Melbourne, Parkville, VIC, Australia
| | | | | | | | | | | | | | | | | | - Karen F Murray
- University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
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Rajabi F, Rodan LH, Jonas MM, Soul JS, Ullrich NJ, Wessel A, Waisbren SE, Tan WH, Berry GT. Liver Failure as the Presentation of Ornithine Transcarbamylase Deficiency in a 13-Month-Old Female. JIMD Rep 2017; 40:17-22. [PMID: 28887792 DOI: 10.1007/8904_2017_55] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/16/2017] [Accepted: 08/18/2017] [Indexed: 01/31/2023] Open
Abstract
Ornithine transcarbamylase deficiency (OTCD) is an X-linked urea cycle disorder with variable expressivity in heterozygous females. While liver function testing is often abnormal in patients with OTCD, liver failure is uncommon on presentation. A 13-month-old female with no significant past medical history presented with irritability, right arm weakness, and decreased appetite. Initial workup revealed hepatic dysfunction with an INR of 3.4, ammonia level of 75 μmol/L, and abnormal brain MRI with gyral edema with restricted diffusion, and patchy signal abnormality in basal ganglia. The MRI findings led to a putative diagnosis of acute disseminated encephalomyelitis prompting corticosteroid treatment. As steroid treatment was begun, she developed significant hepatocellular dysfunction with ALT 2,222 U/L, AST 630 U/L, prolonged INR, and elevated ammonia (213 μmol/L). Neurologic signs resolved and her ammonia level decreased (43 μmol/L) without further intervention; however, she had ongoing acute liver failure with coagulopathy and episodic irritability, managed as seronegative autoimmune hepatitis with partial response to corticosteroid therapy. At 18 months of age she presented with severe irritability with markedly increased ammonia (417 μmol/L). Plasma amino acids obtained several days prior to this acute episode demonstrated elevation in glutamine (2,725 μmol/L) and alanine (1,459 μmol/L). Biochemical testing demonstrated elevation of urine orotic acid (>240.6 mmol/mol creatinine). Genetic testing confirmed a heterozygous nonsense mutation in the OTC gene (c.958C>T, R320X). After treatment with ammonia scavengers and a protein-restricted diet, hepatic function normalized and irritability resolved. The diagnosis of a urea cycle disorder should be considered in patients with unexplained hepatic dysfunction.
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Affiliation(s)
- Farrah Rajabi
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Lance H Rodan
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Janet S Soul
- Department of Neurology, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Nicole J Ullrich
- Department of Neurology, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Ann Wessel
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Susan E Waisbren
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Wen-Hann Tan
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Gerard T Berry
- Division of Genetics and Genomics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.
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Balistreri WF, Murray KF, Rosenthal P, Bansal S, Lin CH, Kersey K, Massetto B, Zhu Y, Kanwar B, German P, Svarovskaia E, Brainard DM, Wen J, Gonzalez-Peralta RP, Jonas MM, Schwarz K. The safety and effectiveness of ledipasvir-sofosbuvir in adolescents 12-17 years old with hepatitis C virus genotype 1 infection. Hepatology 2017; 66:371-378. [PMID: 27997679 DOI: 10.1002/hep.28995] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 11/23/2016] [Accepted: 12/08/2016] [Indexed: 12/11/2022]
Abstract
UNLABELLED No all-oral, direct-acting antiviral regimens have been approved for children with chronic hepatitis C virus (HCV) infection. We conducted a phase 2, multicenter, open-label study to evaluate the efficacy and safety of ledipasvir-sofosbuvir in adolescents with chronic HCV genotype 1 infection. One hundred patients aged 12-17 years received a combination tablet of 90 mg ledipasvir and 400 mg sofosbuvir once daily for 12 weeks. On the tenth day following initiation of dosing, 10 patients underwent an intensive pharmacokinetic evaluation of the concentrations of sofosbuvir, ledipasvir, and the sofosbuvir metabolite GS-331007. The primary efficacy endpoint was the percentage of patients with a sustained virologic response at 12 weeks posttreatment. Median age of patients was 15 years (range 12-17). A majority (80%) were HCV treatment-naive, and 84% were infected through perinatal transmission. One patient had cirrhosis, and 42 did not; in 57 patients the degree of fibrosis was unknown. Overall, 98% (98/100; 95% confidence interval 93%-100%) of patients reached sustained virologic response at 12 weeks. No patient had virologic failure. The 2 patients who did not achieve sustained virologic response at 12 weeks were lost to follow-up either during or after treatment. The three most commonly reported adverse events were headache (27% of patients), diarrhea (14%), and fatigue (13%). No serious adverse events were reported. Area under the concentration-time curve (tau) and maximum concentration values for sofosbuvir, ledipasvir, and GS-331007 were within the predefined pharmacokinetic equivalence boundaries of 50%-200% when compared with adults from phase 2 and 3 studies of ledipasvir and sofosbuvir. CONCLUSION Ledipasvir-sofosbuvir was highly effective at treating adolescents with chronic HCV genotype 1 infection; the dose of ledipasvir-sofosbuvir currently used in adults was well tolerated in adolescents and had an appropriate pharmacokinetic profile. (Hepatology 2017;66:371-378).
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Affiliation(s)
| | | | | | | | | | | | | | - Yanni Zhu
- Gilead Sciences, Inc., Foster City, CA
| | | | | | | | | | - Jessica Wen
- The Children's Hospital of Philadelphia, Philadelphia, PA
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Valentino PL, Jonas MM, Lee CK, Kim HB, Vakili K, Elisofon SA. Outcomes after discontinuation of routine use of transanastomotic biliary stents in pediatric liver transplantation at a single site. Pediatr Transplant 2016; 20:647-51. [PMID: 27239056 DOI: 10.1111/petr.12729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2016] [Indexed: 01/24/2023]
Abstract
Routine use of transanastomotic biliary stents (RTBS) for biliary reconstruction in liver transplantation (LT) is controversial, with conflicting outcomes in adult randomized trials. Pediatric literature contains limited data. This study is a retrospective review of 99 patients who underwent first LT (2005-2014). In 2011, RTBS was discontinued at our center. This study describes biliary complications following LT with and without RTBS. 56 (56%) patients had RTBS. Median age at LT was 1.9 yr (IQR 0.7, 8.6); 55% were female. Most common indication for LT was biliary atresia (36%). Most common biliary reconstruction was Roux-en-Y choledochojejunostomy (75% with RTBS, 58% without RTBS, p = 0.09). Biliary complications (strictures, bile leaks, surgical revision) occurred in 23% without significant difference between groups (20% with RTBS, 28% without RTBS, p = 0.33). Patients with RTBS had routine cholangiography via the tube at 6-8 wk; thus, significantly more patients with RTBS had cholangiograms (91% vs. 19%, p < 0.0001). There was no difference in the number of patients who required therapeutic intervention via endoscopic or percutaneous transhepatic cholangiography (11% with RTBS, 19% no RTBS, p = 0.26). Routine use of RTBS for biliary reconstruction in pediatric LT may not be necessary, and possibly associated with need for costlier, invasive imaging without improvement in outcomes.
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Affiliation(s)
- Pamela L Valentino
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christine K Lee
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Heung B Kim
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Khashayar Vakili
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott A Elisofon
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Desai NK, Harney S, Raza R, Al-Ibraheemi A, Shillingford N, Mitchell PD, Jonas MM. Comparison of Controlled Attenuation Parameter and Liver Biopsy to Assess Hepatic Steatosis in Pediatric Patients. J Pediatr 2016; 173:160-164.e1. [PMID: 27039224 PMCID: PMC5105890 DOI: 10.1016/j.jpeds.2016.03.021] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [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: 10/27/2015] [Revised: 01/25/2016] [Accepted: 03/01/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess whether the degree of steatosis as determined by controlled attenuation parameter (CAP) measurements correlates with that observed on liver biopsies in a single-center pediatric and young adult cohort. STUDY DESIGN This cross-sectional study included patients undergoing liver biopsy as part of standard clinical care between January 25, 2012, and April 1, 2015, at Boston Children's Hospital. Eligible patients, with a variety of liver diseases, had CAP measurements within 1 year of biopsy. CAP values were compared across histologic steatosis grades using ANOVA. RESULTS Sixty-nine patients (mean age, 16.0 ± 2.9 years; 62% male) were studied. CAP measurements were obtained at a median of 1.3 months (IQR, 0.5-3.2) after biopsy. Of the 69 subjects, 23 had steatosis on biopsy. Mean CAP value (dB/m) for subjects with no steatosis was 198 ± 37 vs 290 ± 47 for subjects with steatosis (P < .0001). There were statistically significant differences between CAP values in individuals with no steatosis vs mild/moderate steatosis (P < .0001), no steatosis vs marked steatosis (P < .0001), and mild/moderate vs marked steatosis (P = .004). CONCLUSION This study demonstrated a difference in CAP between no steatosis and steatosis, and between grades of steatosis. CAP may be a useful noninvasive tool to detect hepatic steatosis in children.
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Affiliation(s)
- Nirav K. Desai
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Sarah Harney
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Roshan Raza
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | | | | | - Paul D. Mitchell
- Clinical Research Center, Boston Children’s Hospital, Boston, MA
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
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Jonas MM, Chang MH, Sokal E, Schwarz KB, Kelly D, Kim KM, Ling SC, Rosenthal P, Oraseanu D, Reynolds L, Thiry A, Ackerman P. Randomized, controlled trial of entecavir versus placebo in children with hepatitis B envelope antigen-positive chronic hepatitis B. Hepatology 2016. [PMID: 26223345 DOI: 10.1002/hep.28015] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED This ongoing, randomized phase III study assesses the safety and efficacy of entecavir versus placebo in nucleos(t)ide-naïve children (2 to <18 years) with hepatitis B envelope antigen (HBeAg)-positive chronic hepatitis B (CHB). Blinded treatment was administered for a minimum of 48 weeks. After week 48, patients with HBeAg seroconversion continued blinded treatment; those without switched to open-label entecavir. The primary endpoint was HBeAg seroconversion and HBV DNA <50 IU/mL at week 48. A total of 180 patients were randomized (2:1) and treated. Baseline median age was 12 years, with approximately 50% of children ages >12 to <18, and 25% each ages ≥2 to ≤6 and >6 to ≤12. Rates for the primary endpoint at week 48 were significantly higher with entecavir than placebo (24.2% [29 of 120] vs. 3.3% [2 of 60]; P = 0.0008). Furthermore, higher response rates were observed with entecavir compared with placebo for the key week 48 secondary endpoints: HBV DNA <50 IU/mL (49.2% [59 of 120] vs. 3.3% [2 of 60]; P < 0.0001); alanine aminotransferase normalization (67.5% [81 of 120] vs. 23.3% [14 of 60]; P < 0.0001); and HBeAg seroconversion (24.2% [29 of 120] vs. 10.0% [6 of 60]; P = 0.0210). Among entecavir-randomized patients, there was an increase in all efficacy endpoints between weeks 48 and 96, including an increase from 49% to 64% in virological suppression. The cumulative probability of emergent entecavir resistance through years 1 and 2 of entecavir was 0.6% and 2.6%, respectively. Entecavir was well tolerated with no observed differences in adverse events or changes in growth compared with placebo. CONCLUSION In childhood CHB, entecavir demonstrated superior antiviral efficacy to placebo with a favorable safety profile. These results support the use of entecavir as a therapeutic option in children and adolescents with CHB.
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Affiliation(s)
| | | | - Etienne Sokal
- Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | | | - Kyung Mo Kim
- Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Simon C Ling
- The Hospital For Sick Children, and Department of Pediatrics, University of Toronto, Toronto, Canada
| | | | - Dumitru Oraseanu
- Grigore Alexandrescu Emergency Hospital for Children, Bucharest, Romania
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Terrault NA, Bzowej NH, Chang KM, Hwang JP, Jonas MM, Murad MH. AASLD guidelines for treatment of chronic hepatitis B. Hepatology 2016; 63:261-83. [PMID: 26566064 PMCID: PMC5987259 DOI: 10.1002/hep.28156] [Citation(s) in RCA: 1460] [Impact Index Per Article: 182.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 08/25/2015] [Indexed: 12/11/2022]
Affiliation(s)
| | | | - Kyong-Mi Chang
- Corporal Michael J. Crescenz VA Medical Center & University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jessica P Hwang
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maureen M Jonas
- Boston Children's Hospital, Harvard Medical School, Boston, MA
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36
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Jonas MM, Lok ASF, McMahon BJ, Brown RS, Wong JB, Ahmed AT, Farah W, Mouchli MA, Singh S, Prokop LJ, Murad MH, Mohammed K. Antiviral therapy in management of chronic hepatitis B viral infection in children: A systematic review and meta-analysis. Hepatology 2016; 63:307-18. [PMID: 26566163 DOI: 10.1002/hep.28278] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/04/2015] [Indexed: 12/13/2022]
Abstract
UNLABELLED Most individuals with chronic hepatitis B viral (HBV) infection acquired the infection around the time of birth or during early childhood. We aimed to synthesize evidence regarding the effectiveness of antiviral therapy in the management of chronic HBV infection in children. We conducted a comprehensive search of multiple databases from 1988 to December 2, 2014, for studies that enrolled children (<18 years) with chronic HBV infection treated with antiviral therapy. We included observational studies and randomized controlled trials (RCTs). Two independent reviewers selected studies and extracted data. In the 14 included studies, two cohort studies showed no significant reduction in the already low risk of hepatocellular carcinoma or cirrhosis and 12 RCTs reported intermediate outcomes. In RCTs with posttreatment follow-up <12 months, antiviral therapy compared to placebo improved alanine aminotransferase normalization (risk ratio [RR] = 2.3, 95% confidence interval [CI] 1.7-3.2), hepatitis B e antigen (HBeAg) clearance/loss (RR = 2.1, 95% CI 1.5-3.1), HBV DNA suppression (RR = 2.9, 95% CI 1.8-4.6), HBeAg seroconversion (RR = 2.1, 95% CI 1.4-3.3), and hepatitis B surface antigen clearance (RR = 5.8, 95% CI 1.1-31.5). In RCTs with posttreatment follow-up ≥12 months, antiviral therapy improved cumulative HBeAg clearance/loss (RR = 1.9, 95% CI 1.7-3.1), HBeAg seroconversion (RR = 2.1, 95% CI 1.3-3.5), alanine aminotransferase normalization (RR = 1.4, 95% CI 1.1-1.7), and HBV DNA suppression (RR = 1.4, 95% CI 1.1-1.8) but not hepatitis B surface antigen clearance or seroconversion. CONCLUSION In children with chronic HBV infection, antivirals compared to no antiviral therapy improve HBV DNA suppression and frequency of alanine aminotransferase normalization and HBeAg seroconversion.
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Affiliation(s)
- Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Anna S F Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Brian J McMahon
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, AK
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY
| | - John B Wong
- Department of Medicine, Tufts Medical Center, Boston, MA
| | - Ahmed T Ahmed
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, MN.,Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Wigdan Farah
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, MN.,Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Siddharth Singh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Mohammad Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, MN.,Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.,Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, MN
| | - Khaled Mohammed
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, MN.,Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.,Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, MN
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Abstract
Hepatitis C infection is a global health problem. Most infected children have not been identified. Perinatal transmission is the most common mode of acquisition. Liver disease owing to chronic hepatitis C virus (HCV) infection progresses slowly in individuals infected early in life. Serious complications rarely affect patients during childhood. Successful treatment of HCV in adults has improved and recommendations have changed. Treatment in children should be deferred until direct-acting antivirals and interferon-free regimens are available to this population. If treatment cannot be deferred, regimens including peginterferon and ribavirin can be given to children with compensated liver disease.
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Affiliation(s)
- Christine K Lee
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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Wu FM, Jonas MM, Opotowsky AR, Harmon A, Raza R, Ukomadu C, Landzberg MJ, Singh MN, Valente AM, Egidy Assenza G, Perez-Atayde AR. Portal and centrilobular hepatic fibrosis in Fontan circulation and clinical outcomes. J Heart Lung Transplant 2015; 34:883-91. [DOI: 10.1016/j.healun.2015.01.993] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 01/19/2015] [Accepted: 01/31/2015] [Indexed: 10/24/2022] Open
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Affiliation(s)
- Christine K. Lee
- Division of Gastroenterology, Hepatology and NutritionBoston Children's HospitalBostonMA
| | - Maureen M. Jonas
- Division of Gastroenterology, Hepatology and NutritionBoston Children's HospitalBostonMA
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40
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Jonas MM, Schwarz KB, Gonzalez-Peralta R, Lobritto S, Molleston JP, Murray KF, Rosenthal P, Wen J, Wat C, Pavlovic V, Warne C. Long-term growth outcomes in children treated for chronic hepatitis C. J Pediatr 2014; 165:1252-4. [PMID: 25241178 DOI: 10.1016/j.jpeds.2014.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 06/05/2014] [Accepted: 08/07/2014] [Indexed: 10/24/2022]
Abstract
Effects on linear growth were noted in children treated with peginterferon ± ribavirin in the Pediatric Study of Hepatitis C trial. Growth was further examined in a subset of patients followed for up to 6 years post-treatment. No long-term effects on height-for-age z scores were observed that could be attributed to hepatitis C virus treatment.
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Affiliation(s)
- Maureen M Jonas
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA.
| | - Kathleen B Schwarz
- Division of Pediatric Gastroenterology and Nutrition, Johns Hopkins Children's Center, Baltimore, MD
| | - Regino Gonzalez-Peralta
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, UF Health Children's Hospital, Gainesville, FL
| | - Steven Lobritto
- Department of Pediatrics and Internal Medicine, NY Presbyterian Hospital, Morgan Stanley Children's Hospital, New York, NY
| | - Jean P Molleston
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Riley Hospital for Children, Indianapolis, IN
| | - Karen F Murray
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, WA
| | - Philip Rosenthal
- Departments of Pediatrics and Surgery, UCSF Benioff Children's Hospital, San Francisco, CA
| | - Jessica Wen
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Cynthia Wat
- Roche Products Limited, Welwyn Garden City, United Kingdom
| | | | - Charles Warne
- Roche Products Limited, Welwyn Garden City, United Kingdom
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Wu FM, Opotowsky AR, Raza R, Harney S, Ukomadu C, Landzberg MJ, Valente AM, Breitbart RE, Singh MN, Gauvreau K, Jonas MM. Transient elastography may identify Fontan patients with unfavorable hemodynamics and advanced hepatic fibrosis. CONGENIT HEART DIS 2014; 9:438-47. [PMID: 24418160 DOI: 10.1111/chd.12159] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [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] [Accepted: 12/02/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND Transient elastography (TE) offers a noninvasive correlate with the degree of hepatic fibrosis. However, factors other than fibrosis affect liver stiffness. We sought to determine whether hepatic congestion related to hemodynamics in Fontan circulation influences liver stiffness measurement (LSM) assessed by TE. METHODS We studied 45 subjects with Fontan circulation undergoing cardiac catheterization with or without simultaneous liver biopsy. Subjects underwent TE within 5 days before catheterization. Clinical history, hemodynamic and biopsy data, and hepatic biomarkers were collected. Five subjects who had previously undergone liver biopsy and TE were also included. RESULTS Median age was 13.1 years (range 2.4-57.8); median time since Fontan was 9.9 years (range 0.1-32.5). No subject had known hepatitis C. Mean LSM for the entire cohort was 21.4 ± 10.8 kPa. Univariate regression analysis using LSM as a continuous outcome variable shows significant correlations with age (R = 0.35, P = .01), time since Fontan (R = 0.41, P = .003), Fontan pressure (R = 0.31, P = .04), cardiac index (R = 0.33, P = .03), pulmonary vascular resistance (R = 0.34, P = .03), systemic arterial oxygen saturation (R = 0.31, P = .04), and platelet count (R = 0.29, P = .05). On multiple regression analysis, Fontan pressure (β = 0.901, P = .03) and cardiac index (β = 2.703, P = .02) were significant predictors of LSM with overall model R(2) = 0.206. Univariate analysis shows LSM to be associated with more severe centrilobular fibrosis (P = .05). CONCLUSIONS Higher LSM is associated with unfavorable Fontan hemodynamics and advanced centrilobular hepatic fibrosis. TE may be a useful tool for identifying Fontan patients who warrant invasive testing.
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Affiliation(s)
- Fred M Wu
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass, USA; Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass, USA
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Lee CK, Perez-Atayde AR, Mitchell PD, Raza R, Afdhal NH, Jonas MM. Serum biomarkers and transient elastography as predictors of advanced liver fibrosis in a United States cohort: the Boston children's hospital experience. J Pediatr 2013; 163:1058-64.e2. [PMID: 23759423 DOI: 10.1016/j.jpeds.2013.04.044] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 03/26/2013] [Accepted: 04/23/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate and compare the ability of serum hyaluronic acid (HA) and human cartilage glycoprotein-39 (YKL-40) values, as well as transient elastography (TE) findings, to predict advanced hepatic fibrosis in a cohort from a single pediatric center. STUDY DESIGN Subjects who underwent liver biopsy analysis within 12 months before enrollment were eligible for this prospective study. HA and YKL-40 measurements were obtained within 1 month of TE. A METAVIR score of F3 or F4 was considered to indicate advanced fibrosis. RESULTS A total of 128 patients (51% males) aged 1.4 months to 27.6 years (22% aged <2 years) were enrolled. Thirty-one subjects had data on only HA and YKL-40 measurements, and 97 subjects had data on both blood tests and TE. For the prediction of advanced fibrosis, the area under the receiver operating characteristic curve (AUC) values were 0.83 for TE, 0.72 for HA, and 0.52 for YKL-40. The AUC of 0.83 for TE was statistically significantly greater than the AUCs for HA (P = .03) and YKL-40 (P < .0001). Optimal cutpoints for predicting F3-F4 fibrosis were 8.6 kPa for TE (P < .0001), 43 ng/mL for HA (P < .0001), and 26.2 ng/mL for YKL-40 (P = .85). The combination of TE and HA was not better than TE alone for predicting advanced fibrosis (P = .15). CONCLUSION In this study, which evaluated TE, HA, and YKL-40 to predict liver fibrosis in children in the US, YKL-40 had no predictive value and TE was superior to HA, but the addition of HA did not improve the performance of TE. Our data suggest that TE and HA may be useful noninvasive tools for assessing liver fibrosis in children.
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Affiliation(s)
- Christine K Lee
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA.
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Ramon-Krauel M, Salsberg SL, Ebbeling CB, Voss SD, Mulkern RV, Apura MM, Cooke EA, Sarao K, Jonas MM, Ludwig DS. A low-glycemic-load versus low-fat diet in the treatment of fatty liver in obese children. Child Obes 2013; 9:252-60. [PMID: 23705885 PMCID: PMC3675832 DOI: 10.1089/chi.2013.0022] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Fatty liver is highly prevalent among obese children and represents a major risk factor for chronic liver diseases and severe metabolic complications. METHODS We randomly assigned 17 obese children 8-17 years of age with fatty liver to either an experimental low-glycemic-load or conventional low-fat diet for 6 months. Participants in both groups received nutrition education and behavioral counseling of equal intensity. The primary outcome was hepatic lipid content measured by proton magnetic resonance spectroscopy. Secondary outcomes included change in visceral fat, BMI, anthropometrics, alanine aminotransferase (ALT), and insulin resistance. RESULTS A total of 16 participants completed the study. Reported glycemic load decreased in the low-glycemic-load group and reported dietary fat decreased in the low-fat group. At baseline, liver fat was 23.8% [standard deviation (SD) 12.2] in the low-glycemic-load group and 29.3% (14.1) in the low-fat group. Liver fat decreased substantially in both groups at 6 months expressed as absolute percentage change, with no between-group differences [-8.8 (standard error (SE) 4.1) vs. -10.5 (3.7)%, respectively, p=0.76 for group×time interaction]. Secondary outcomes also improved on both diets, with no between-group differences. Baseline and change in ALT were strongly associated with hepatic fat content. CONCLUSIONS Weight-reducing diets focused either on glycemic load or dietary fat improved hepatic steatosis over 6 months. Additional research is needed to determine whether these diets differ in effectiveness over the long term. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00480922.
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Affiliation(s)
- Marta Ramon-Krauel
- New Balance Foundation Obesity Prevention Center, Department of Medicine, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA.,These authors contributed equally to this study
| | - Sandra L. Salsberg
- New Balance Foundation Obesity Prevention Center, Department of Medicine, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA.,These authors contributed equally to this study
| | - Cara B. Ebbeling
- New Balance Foundation Obesity Prevention Center, Department of Medicine, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Stephan D. Voss
- Department of Radiology, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Robert V. Mulkern
- Department of Radiology, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Margaret M. Apura
- New Balance Foundation Obesity Prevention Center, Department of Medicine, Boston Children's Hospital, Boston, MA
| | - Emily A. Cooke
- New Balance Foundation Obesity Prevention Center, Department of Medicine, Boston Children's Hospital, Boston, MA
| | - Karen Sarao
- Department of Radiology, Boston Children's Hospital, Boston, MA
| | - Maureen M. Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - David S. Ludwig
- New Balance Foundation Obesity Prevention Center, Department of Medicine, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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Affiliation(s)
- Maureen M. Jonas
- From the Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Abstract
Prematurity and very low birthweight have often been considered relative contraindications to neonatal organ donation. Organ procurement from neonatal donors is further complicated by unclear guidelines regarding neonatal brain death. We report a successful case of multivisceral transplantation using a graft from a 10-day-old, 2.9 kg, neonatal donor born at 36 6/7 wk in a 3.2 kg, three month old with intestinal and liver failure secondary to midgut volvulus. There was immediate liver graft function with correction of recipient coagulopathy, but delayed normalization of laboratory values and delayed return of bowel function. At six-yr post-transplant follow-up, the patient has normal intestine and liver function. Her last histologically confirmed rejection episode was 30 months prior to last follow-up. This case suggests that multivisceral grafts from very young or small neonatal donors may be transplanted successfully in selected cases. We propose a re-examination of the brain death guidelines for premature and young infants to potentially increase the availability of organs for infant recipients.
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Affiliation(s)
- R P Cauley
- Department of Surgery, Children's Hospital Boston, Boston, MA 02115, USA
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Delgado-Borrego A, Smith L, Jonas MM, Hall CA, Negre B, Jordan SH, Ogrodowicz M, Raza R, Ludwig DA, Miller T, Lipshultz SE, Gonzalez-Peralta R, Chung RT. Expected and actual case ascertainment and treatment rates for children infected with hepatitis C in Florida and the United States: epidemiologic evidence from statewide and nationwide surveys. J Pediatr 2012; 161:915-21. [PMID: 22765955 DOI: 10.1016/j.jpeds.2012.05.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 03/26/2012] [Accepted: 05/02/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the rate of pediatric hepatitis C virus (HCV) case ascertainment relative to the estimated number of actual cases. STUDY DESIGN Data from Florida and United States health departments were used to assess pediatric HCV case ascertainment rates in Florida and nationwide. The percentage of children infected with HCV from Miami-Dade County receiving medical care by a pediatric gastroenterologist was estimated based on data obtained from physician questionnaires. RESULTS From 2000 through 2009, 2007 children were identified as having positive HCV antibody tests in Florida, only 12% of the expected number (n = 12 155). An estimated 1.6% of the expected children with HCV who tested Ab-positive (37 of 1935) were actively followed by a pediatric gastroenterologist in Miami-Dade County, Florida. Across the United States, only 4.9% of the expected cases have been identified. CONCLUSIONS The identification of children infected with HCV in the nation as a whole is grossly inadequate. Only a small fraction of cases are identified. In Florida, less than 2% of children identified receive treatment. Lack of identification and lack of treatment of children infected with HCV constitute critical public health problems. Strategies to increase awareness of HCV infection and to screen at-risk individuals could substantially improve morbidity and mortality while reducing health care costs.
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Affiliation(s)
- Aymin Delgado-Borrego
- Department of Pediatrics, Batchelor Children's Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA.
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Jonas MM, Balistreri W, Gonzalez-Peralta RP, Haber B, Lobritto S, Mohan P, Molleston JP, Murray KF, Narkewicz MR, Rosenthal P, Schwarz KB, Barton BA, Shepherd JA, Mitchell PD, Duggan C. Pegylated interferon for chronic hepatitis C in children affects growth and body composition: results from the pediatric study of hepatitis C (PEDS-C) trial. Hepatology 2012; 56:523-31. [PMID: 22383118 PMCID: PMC3382022 DOI: 10.1002/hep.25690] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 02/20/2012] [Indexed: 12/12/2022]
Abstract
UNLABELLED Weight loss and changes in growth are noted in children treated with interferon alpha (IFN-α). The aim of this study was to prospectively determine changes in weight, height, body mass index (BMI), and body composition during and after treatment of children with hepatitis C virus (HCV). Children treated with pegylated interferon alpha-2a (Peg-IFN-α2a) ± ribavirin in the Pediatric Study of Hepatitis C (PEDS-C) trial underwent anthropometric measurements, dual-energy X-ray absorptiometry scan, as well as dietary and activity assessments during and after treatment. One hundred and fourteen (55% male) children, with a mean age of 11 ± 3 years, were randomized, and 107 received treatment for at least 24 weeks. Subjects were divided into three groups according to duration of treatment: 24 (N = 14), 48 (N = 82), or 72 (N = 11) weeks. Decrements of up to 0.50 z score were observed for weight, height, and BMI while on therapy among all groups (P ≤ 0.01, compared to baseline). In the group treated for 48 weeks, 29 (33%) subjects had greater than 0.5-unit decrement in height-for-age z (HAZ) score. Though weight-for-age and BMI z scores returned to baseline after cessation of therapy, mean HAZ score was slower to rebound, still lower than baseline at 96 weeks post-therapy for the long-treatment duration group (P = 0.03) and lower than baseline in most children treated for 48 weeks. Percent body fat, fat-free mass z scores, and triceps skinfold z scores decreased with therapy. Dietary energy intake and levels of physical activity did not change during treatment. CONCLUSIONS Peg-IFN-α2a was associated with significant changes in body weight, linear growth, BMI, and body composition in children. These effects were generally reversible with cessation of therapy, although HAZ scores had not returned to baseline after 2 years of observation in many. Longer term growth data are needed among children treated for chronic HCV.
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Affiliation(s)
| | | | | | - Barbara Haber
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - Steven Lobritto
- Morgan Stanley Children's Hospital of New York, New York, NY
| | | | | | | | - Michael R. Narkewicz
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | | | | | - Bruce A. Barton
- University of Massachusetts School of Medicine, Worcester, MA
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Jonas MM, Kelly D, Pollack H, Mizerski J, Sorbel J, Frederick D, Mondou E, Rousseau F, Sokal E. Efficacy and safety of long-term adefovir dipivoxil therapy in children with chronic hepatitis B infection. Pediatr Infect Dis J 2012; 31:578-82. [PMID: 22466329 DOI: 10.1097/inf.0b013e318255ffe7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The safety and efficacy of adefovir dipivoxil (ADV) for chronic hepatitis B infection in children was demonstrated in a randomized, placebo-controlled trial. Those children were followed for 4 more years, and many continued to receive ADV for all or part of this time. OBJECTIVES To examine the therapeutic effects and safety of prolonged ADV therapy in children with chronic hepatitis B infection. METHODS After 48 weeks of double-blind treatment, all placebo-treated subjects who did not exhibit HBeAg seroconversion at week 44, and all ADV-treated subjects, were offered open-label ADV for up to 192 additional weeks. Treatment was discontinued if there was no virologic effect, except for adolescents with previous lamivudine exposure, in whom lamivudine was added to ADV. Durability of HBeAg seroconversion was assessed. Annual resistance surveillance was conducted in subjects who had detectable hepatitis B virus DNA. RESULTS Of the 170 subjects who completed the 48-week study, 162 participated in the open-label study. ADV was discontinued in 61 subjects due to virologic failure. In subjects who continued treatment, either as monotherapy or with lamivudine, continued viral suppression and alanine aminotransferase normalization were noted. HBeAg seroconversions were observed in 55 subjects, and hepatitis B surface antigen seroconversion in 5. Mean duration of HBeAg seroconversion at last observation was 762 ± 371.2 days in the ADV-ADV group and 643 ± 291.5 days in the PLB-ADV group. ADV was safe and well-tolerated. Resistance to ADV was observed in 1 child on ADV monotherapy. Nine treatment-experienced subjects entered the study with mutations associated with lamivudine resistance. All responded to ADV therapy. CONCLUSIONS Prolonged ADV treatment is safe in children. If reserved only for those with virologic response within 6 months, viral resistance was minimal.
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Affiliation(s)
- Maureen M Jonas
- Division of Gastroenterology, Children's Hospital Boston, Boston, MA 02115, USA.
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Kelly DA, Haber B, González-Peralta RP, Murray KF, Jonas MM, Molleston JP, Narkewicz MR, Sinatra FR, Lang T, Lachaux A, Wirth S, Shelton M, Te HS, Pollack H, Deng W, Noviello S, Albrecht JK. Durability of sustained response shown in paediatric patients with chronic hepatitis C who were treated with interferon alfa-2b plus ribavirin. J Viral Hepat 2012; 19:263-70. [PMID: 22404724 DOI: 10.1111/j.1365-2893.2011.01544.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Long-term studies in adults indicate that sustained virologic response (SVR) after combination treatment for chronic hepatitis C (CHC) predicts long-term clearance. Although peginterferon plus ribavirin is now standard care for children with CHC, long-term follow-up studies are not yet available. This study evaluated durability of virologic response over 5 years in children previously treated with interferon alfa-2b plus ribavirin (IFN/R). Ninety-seven of 147 children with CHC, who were treated with IFN/R and completed the 6-month follow-up in two previous clinical trials, participated in this long-term follow-up study. All were assessed annually for up to 5 years; patients with SVR were assessed for durability of virologic response. Children with SVR (n = 56) and those with detectable hepatitis C virus (HCV) RNA 24-week post-treatment (n = 41) were followed for a median of 284 weeks. Overall, 70% (68/97) of patients completed the 5-year follow-up. One patient with genotype 1a CHC had SVR and relapsed at year 1 of follow-up with the same genotype. Kaplan-Meier estimate for sustained response at 5 years was 98% (95% CI: 95%, 100%). Six patients with low-positive HCV RNA levels (n = 4) or missing HCV RNA at the 24-week follow-up visit (n = 2) in the initial treatment studies had virologic response during this long-term follow-up study. Linear growth rate was impaired during treatment with rapid increases in the immediate 6 months post-treatment. Mean height percentile at the end of the 5-year follow-up was slightly less than the mean pretreatment height percentile. Five patients experienced serious adverse events; none related to study drug exposure. SVR after IFN/R predicts long-term clearance of HCV in paediatric patients; growth normalized in the majority of children during the long-term follow-up. Similar long-term results could be expected after peginterferon alfa-2b plus ribavirin treatment.
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Affiliation(s)
- D A Kelly
- Liver Unit, Birmingham Children's Hospital, Birmingham, UK.
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McGuire MM, Jones BA, Hull MA, Misra MV, Smithers CJ, Feins NR, Jenkins RL, Lillehei CW, Harmon WE, Jonas MM, Kim HB. Combined en bloc liver-double kidney transplantation in an infant with IVC thrombosis. Pediatr Transplant 2011; 15:E142-4. [PMID: 20412506 DOI: 10.1111/j.1399-3046.2010.01328.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report a case of a pediatric en bloc liver-double kidney transplant in a patient with IVC thrombosis below the renal veins. The patient is an 11-month-old girl diagnosed with congenital nephrotic syndrome at two months of age. Multifocal liver masses were identified on routine ultrasound at eight months of age. Alpha fetoprotein level was 55 319. Biopsy confirmed hepatoblastoma. CT scan confirmed multiple lesions in both lobes, which would require liver transplantation for resection. She was also found to have thrombosis of her infrarenal IVC secondary to multiple central lines. She was listed for combined liver-kidney transplant and began chemotherapy. After four cycles of chemotherapy, she underwent bilateral nephrectomies followed by a combined en bloc liver-double kidney transplant from a size matched donor. In order to provide adequate venous outflow from the kidneys in the absence of a recipient infrarenal IVC, the donor liver and kidneys were procured en bloc with a common arterial inflow via the infrarenal aorta and common outflow via the suprahepatic IVC. Kidney transplantation in the absence of adequate recipient venous drainage may require unusual vascular reconstruction techniques. This case demonstrates a novel approach in patients who may require combined liver-kidney transplantation.
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