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Ali KM, Zalata KR, Barakat T, Elzeiny SM. Pathologic approach to Neonatal cholestasis with a simple scoring system for biliary atresia. Virchows Arch 2024; 484:93-102. [PMID: 38008855 DOI: 10.1007/s00428-023-03704-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/03/2023] [Accepted: 11/08/2023] [Indexed: 11/28/2023]
Abstract
A liver biopsy is essential for the diagnostic workup of persistent neonatal cholestasis (NC). The differential diagnosis of NC is broad, including obstructive and non-obstructive causes. In addition, histologic features of certain disorders may be non-specific in the early course of the disease. To evaluate liver biopsies using a practical histopathologic approach for NC and to define a simple scoring system for biliary atresia (BA) for routine clinical practice. From June 2006 to December 2021, liver biopsy specimens from infants with persistent NC were examined by two independent pathologists. The cases diagnosed as BA were correlated with clinical, radiologic, and laboratory data to calculate the final score. Four hundred and fifty-nine cases were enrolled in the study. They had a mean age of 63.94 ± 20.62 days and were followed for a median time of 58 (1-191) months. They included 162 (35.3%) cases of BA. On multivariate analysis, portal edema, ductular proliferation, cholangiolitis, and bile duct/ductular plugs were the histopathologic predictors of BA. A liver biopsy did perform well with a 95.1% sensitivity, 91.6% specificity, 86% PPV, and 97.1% NPV. At a cutoff of 5 of the scoring system, diagnosis of BA could be done with a sensitivity of 95.1% and a specificity of 100%. We have shown detailed histopathologic features of BA with more depth to infants aged ≤ 6 weeks. We have developed a simple scoring system using a combination of liver biopsy with non-invasive methods to increase the diagnostic accuracy of BA.
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Affiliation(s)
- Khadiga M Ali
- Pathology Department, Faculty of Medicine, Mansoura University, Elgomhoria Street, Mansoura, Eldakahliya, 35516, Egypt.
| | - Khaled R Zalata
- Pathology Department, Faculty of Medicine, Mansoura University, Elgomhoria Street, Mansoura, Eldakahliya, 35516, Egypt
| | - Tarik Barakat
- Gastroenterology and Hepatology Unit, Mansoura Faculty of Medicine, Mansoura Children Hospital, Mansoura, Egypt
| | - Sherine M Elzeiny
- Gastroenterology and Hepatology Unit, Mansoura Faculty of Medicine, Mansoura Children Hospital, Mansoura, Egypt
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Samanta A, Sarma MS, Srivastava A, Poddar U. Cholestatic Liver Disease in a Child with KIF12 Mutation. Indian J Pediatr 2023:10.1007/s12098-023-04914-0. [PMID: 37919484 DOI: 10.1007/s12098-023-04914-0] [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: 07/30/2023] [Accepted: 10/19/2023] [Indexed: 11/04/2023]
Abstract
Cholestatic liver diseases in children often have an underlying genetic defect. Genetic testing by next-generation sequencing has become a crucial part of the diagnostic armamentarium in such clinical scenarios. Here, authors report an infant with recurrent cholestasis, pruritus, elevated gamma-glutamyl transpeptidase, patent biliary tract and biliary changes on histology who was detected to have a novel KIF12 mutation, which is crucial for intracellular transport of microtubules and cellular polarity in hepatocytes. The child developed progressive liver dysfunction and decompensation in the form of ascites and coagulopathy over a span of eight years. This case highlights the role of next-generation sequencing in identifying novel mutations, which can help in both diagnosis and prognostication.
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Affiliation(s)
- Arghya Samanta
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India.
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
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Heinz N, Vittorio J. Treatment of Cholestasis in Infants and Young Children. Curr Gastroenterol Rep 2023; 25:344-354. [PMID: 37651067 DOI: 10.1007/s11894-023-00891-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE OF REVIEW Cholestasis is characterized by a conjugated hyperbilirubinemia secondary to impaired bile synthesis, transport, or excretion from the liver. It is always pathologic and can be indicative of an underlying hepatobiliary, genetic, or metabolic disorder, several of which require timely diagnosis to ensure proper management and optimal outcomes. This review provides an overview of the evaluation of cholestasis with a focus on current and emerging treatment strategies. RECENT FINDINGS Increased accessibility of next generation sequencing (NGS) allows for utilization of genetic testing early in the diagnostic process. This may alter the clinical algorithm for diagnosis of cholestatic disorders. An enhanced understanding of the underlying pathophysiology may help guide future development of targeted therapies, such as ileal bile acid transporter (IBAT) inhibitors. These were recently approved for treatment of cholestatic pruritus in patients with Alagille syndrome and Progressive Familial Intrahepatic Cholestasis. Current management of cholestasis is aimed at the biochemical consequences of impaired bile flow, including malnutrition, pruritus, and progressive fibrosis. NGS has led to an enhanced understanding of biliary pathology and may guide development of future treatment modalities based on specific gene mutations. Rapid discernment of the underlying etiology is essential as new treatment modalities emerge.
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Affiliation(s)
- Nicole Heinz
- New York University (NYU) Transplant Institute, NYU Langone Health, 160 East 32nd Street, Suite L3 Medical Level, New York, NY, USA
| | - Jennifer Vittorio
- New York University (NYU) Transplant Institute, NYU Langone Health, 160 East 32nd Street, Suite L3 Medical Level, New York, NY, USA.
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Gong Z, Lin L, Lu G, Wan C. Development and validation of a model for early diagnosis of biliary atresia. BMC Pediatr 2023; 23:549. [PMID: 37907911 PMCID: PMC10617173 DOI: 10.1186/s12887-023-04370-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/06/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND AND AIMS Early diagnosis of biliary atresia (BA), particularly distinguishing it from other causes of neonatal cholestasis (NC), is challenging. This study aimed to design and validate a predictive model for BA by using the data available at the initial presentation. METHODS Infants presenting with NC were retrospectively identified from tertiary referral hospitals and constituted the model design cohort (n = 148); others were enrolled in a prospective observational study and constituted the validation cohort (n = 21). Clinical, laboratory, and abdominal ultrasonographic features associated with BA were assessed. A prediction model was developed using logistic regression and decision tree (DT) analyses. RESULTS Three predictors, namely, gamma glutamyl transpeptidase (γGT) level, triangular cord sign (TC sign), and gallbladder abnormalities, were identified as factors for diagnosing BA in multivariate logistic regression, which was used to develop the DT model. The area under the receiver operating characteristic (ROC) curve (AUC) value for the model was 0.905, which was greater than those for γGT level, TC sign, or gallbladder abnormalities alone in the prediction of BA. CONCLUSION A simple prediction model combining liver function and abdominal ultrasonography findings can provide a moderate and early estimate of the risk of BA in patients with NC.
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Affiliation(s)
- Zongrong Gong
- Department of Pediatrics, West China Second Hospital, Sichuan University and Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, No 20, 3rd Section of Renmin South Road, Chengdu, 610041, People's Republic of China
- Department of Respiration, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Lin Lin
- Department of Respiration, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Gen Lu
- Department of Respiration, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Chaomin Wan
- Department of Pediatrics, West China Second Hospital, Sichuan University and Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, No 20, 3rd Section of Renmin South Road, Chengdu, 610041, People's Republic of China.
- Department of Pediatric Infectious Disease, West China Women's and Children's Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Second University Hospital, Sichuan University, Ministry of Education, No 20, 3rd section of Renmin South Road, 610041, Chengdu, P.R. China.
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Muto Y, Suzuki M, Takei H, Saito N, Mori J, Sugimoto S, Imagawa K, Nambu R, Oguri S, Itonaga T, Ihara K, Hayashi H, Murayama K, Kakiyama G, Nittono H, Shimizu T. Dried blood spot-based newborn screening for bile acid synthesis disorders, Zellweger spectrum disorder, and Niemann-Pick type C1 by detection of bile acid metabolites. Mol Genet Metab 2023; 140:107703. [PMID: 37802748 DOI: 10.1016/j.ymgme.2023.107703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVE To examine whether it is possible to screen for bile acid synthesis disorders (BASDs) including peroxisome biogenesis disorder 1a (PBD1A) and Niemann-Pick type C1 (NPC1) at the time of newborn mass screening by measuring the intermediary metabolites of bile acid (BA) synthesis. METHODS Patients with 3β-hydroxy-ΔSuchy et al. (2021)5-C27-steroid dehydrogenase/isomerase (HSD3B7) deficiency (n = 2), 3-oxo-ΔPandak and Kakiyama (n.d.)4-steroid 5β-reductase (SRD5B1) deficiency (n = 1), oxysterol 7α-hydroxylase (CYP7B1) deficiency (n = 1), PBD1A (n = 1), and NPC1 (n = 2) with available dried blood spot (DBS) samples collected in the neonatal period were included. DBSs from healthy neonates at 4 days of age (n = 1055) were also collected for the control. Disease specific BAs were measured by newly optimized liquid chromatography-tandem mass spectrometry with short run cycle (5-min/run). The results were validated by comparing with those obtained by the conventional condition with longer run cycle (76-min/run). RESULTS In healthy specimens, taurocholic acid and cholic acid were the two major BAs which constituted approximately 80% in the measured BAs. The disease marker BAs presented <10%. In BASDs, the following BAs were determined for the disease specific markers: Glyco/tauro 3β,7α,12α-trihydroxy-5-cholenoic acid 3-sulfate for HSD3B7 deficiency (>70%); glyco/tauro 7α,12α-dihydroxy-3-oxo-4-cholenoic acid for SRD5B1 deficiency (54%); tauro 3β-hydroxy-5-cholenoic acid 3-sulfate for CYP7B1 deficiency (94%); 3α,7α,12α-trihydroxy-5β-cholestanoic acid for PBD1A (78%); and tauro 3β,7β-dihydroxy-5-cholenoic acid 3-sulfate for NPC1 (26%). *The % in the parenthesis indicates the portion found in the patient's specimen. CONCLUSIONS Early postnatal screening for BASDs, PBD1A and NPC1 is feasible with the described DBS-based method by measuring disease specific BAs. The present method is a quick and affordable test for screening for these inherited diseases.
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Affiliation(s)
- Yamato Muto
- Department of Pediatrics, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Mitsuyoshi Suzuki
- Department of Pediatrics, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan.
| | - Hajime Takei
- Junshin Clinic Bile Acid Institute, 2-1-24 Haramachi, Meguro-ku, Tokyo 152-0011, Japan
| | - Nobutomo Saito
- Department of Pediatrics, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Jun Mori
- Division of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
| | - Satoru Sugimoto
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Kazuo Imagawa
- Department of Child Health, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Ryusuke Nambu
- Division of Gastroenterology & Hepatology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama-city 330-8777, Japan
| | - Saori Oguri
- Department of Pediatrics, Oita University Faculty of Medicine, 1-1 Oji-shinmachi, Oita 870-0819, Japan
| | - Tomoyo Itonaga
- Department of Pediatrics, Oita University Faculty of Medicine, 1-1 Oji-shinmachi, Oita 870-0819, Japan
| | - Kenji Ihara
- Department of Pediatrics, Oita University Faculty of Medicine, 1-1 Oji-shinmachi, Oita 870-0819, Japan
| | - Hisamitsu Hayashi
- Laboratory of Molecular Pharmacokinetics, Graduate School of Pharmaceutical Science, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Kei Murayama
- Diagnostics and Therapeutics of Intractable Diseases, Intractable Disease Research Center, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Genta Kakiyama
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, 1101 E. Marshall St., Richmond, VA 23298, USA; Central Virginia VA Healthcare System, 1201 Broad Rock Blvd., Richmond, VA 23249, USA
| | - Hiroshi Nittono
- Junshin Clinic Bile Acid Institute, 2-1-24 Haramachi, Meguro-ku, Tokyo 152-0011, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
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Quelhas P, Breton MC, Oliveira RC, Cipriano MA, Teixeira P, Cerski CT, Shivakumar P, Vieira SMG, Kieling CO, Verde I, Santos JLD. HIF-1alpha-pathway activation in cholangiocytes of patients with biliary atresia: An immunohistochemical/molecular exploratory study. J Pediatr Surg 2023; 58:587-594. [PMID: 36150932 DOI: 10.1016/j.jpedsurg.2022.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Biliary atresia is a neonatal disease characterized by choledochal obstruction and progressive cholangiopathy requiring liver transplantation in most patients. Hypoxia-ischemia affecting the biliary epithelium may lead to biliary obstruction. We hypothesized that ischemic cholangiopathy involving disruption of the peribiliary vascular plexus could act as a triggering event in biliary atresia pathogenesis. METHODS Liver and porta hepatis paraffin-embedded samples of patients with biliary atresia or intrahepatic neonatal cholestasis (controls) were immunohistochemically evaluated for HIF-1alpha-nuclear signals. Frozen histological samples were analyzed for gene expression in molecular profiles associated with hypoxia-ischemia. Prospective clinical-laboratory and histopathological data of biliary atresia patients and controls were reviewed. RESULTS Immunohistochemical HIF-1alpha signals localized to cholangiocytes were detected exclusively in liver specimens from biliary atresia patients. In 37.5% of liver specimens, HIF-1alpha signals were observed in biliary structures involving progenitor cell niches and peribiliary vascular plexus. HIF-1alpha signals were also detected in biliary remnants of 81.8% of porta hepatis specimens. Increased gene expression of molecules linked to REDOX status, biliary proliferation, and angiogenesis was identified in biliary atresia liver specimens. In addition, there was a trend towards decreased GSR expression levels in the HIF-1alpha-positive group compared to the HIF-1alpha-negative group. CONCLUSION Activation of the HIF-1alpha pathway may be associated with the pathogenesis of biliary atresia, and additional studies are necessary to confirm the significance of this finding. Ischemic cholangiopathy and REDOX status disturbance are putative explanations for HIF-1alpha activation. These findings may give rise to novel lines of clinical and therapeutic investigation in the BA field.
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Affiliation(s)
- Patrícia Quelhas
- Faculdade de Ciências da Saúde, Centro de Investigação em Ciências da Saúde, Universidade da Beira Interior (CICS-UBI), Covilhã, Portugal
| | - Michele Claire Breton
- Faculdade de Ciências da Saúde, Centro de Investigação em Ciências da Saúde, Universidade da Beira Interior (CICS-UBI), Covilhã, Portugal
| | - Rui Caetano Oliveira
- Serviço de Anatomia Patológica, Centro Hospitalar e Universitário, Universidade de Coimbra (SAP-CHUC), Portugal; Instituto de Biofísica, Faculdade de Medicina, Universidade de Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, Portugal
| | - Maria Augusta Cipriano
- Serviço de Anatomia Patológica, Centro Hospitalar e Universitário, Universidade de Coimbra (SAP-CHUC), Portugal; Instituto de Biofísica, Faculdade de Medicina, Universidade de Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, Portugal
| | - Paulo Teixeira
- Serviço de Anatomia Patológica, Centro Hospitalar e Universitário, Universidade de Coimbra (SAP-CHUC), Portugal; Instituto de Biofísica, Faculdade de Medicina, Universidade de Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, Portugal
| | - Carlos Thadeu Cerski
- Universidade Federal do Rio Grande do Sul (UFRGS), Department of Pathology, Brazil
| | - Pranavkumar Shivakumar
- Divisions of Gastroenterology, Hepatology and Nutrition and The Liver Care Center at Cincinnati Children's Hospital Medical Center, Cincinnati, United States; Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, United States
| | - Sandra Maria Gonçalves Vieira
- Universidade Federal do Rio Grande do Sul (UFRGS), Department of Pediatrics, Brazil; Unidade de Gastroenterologia e Hepatologia, Hospital de Clínicas de Porto Alegre (HCPA), Brazil; Programa de Transplante de Fígado Pediátrico, Hospital de Clínicas de Porto Alegre (HCPA), Brazil
| | - Carlos Oscar Kieling
- Unidade de Gastroenterologia e Hepatologia, Hospital de Clínicas de Porto Alegre (HCPA), Brazil
| | - Ignacio Verde
- Faculdade de Ciências da Saúde, Centro de Investigação em Ciências da Saúde, Universidade da Beira Interior (CICS-UBI), Covilhã, Portugal
| | - Jorge Luiz Dos Santos
- Faculdade de Ciências da Saúde, Centro de Investigação em Ciências da Saúde, Universidade da Beira Interior (CICS-UBI), Covilhã, Portugal.
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Khayat AA, Alkhaldi AJ. Neonatal Lupus presenting with neonatal hemochromatosis-like liver disease that responded to steroids: a case report. BMC Pediatr 2022; 22:630. [PMID: 36329404 PMCID: PMC9632081 DOI: 10.1186/s12887-022-03713-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Neonatal lupus erythematosus is a rare multisystem autoimmune disorder that predominantly involves the heart with congenital heart block but can involve other organs including the liver. The disease results from passage of maternal autoantibodies to the fetus and manifests in various forms depending on the organ involved. Neonatal lupus liver disease manifestations range from benign elevation in aminotransferases to fatal hepatic insufficiency with iron deposition that does not respond to therapy. Only a handful of cases have been reported to date. The antibodies implicated are Sjogren Syndrome types A and B antibodies. Other non-specific autoantibodies can be positive as well such as antinuclear antibodies. Smooth muscle antibodies are classically considered specific to autoimmune hepatitis, and while they have been described in other chronic liver diseases, they have not been described in neonatal lupus liver disease. Herein we report a rare case of neonatal cholestasis due to neonatal lupus liver disease that presented with a positive smooth muscle antibodies in addition to a biochemical picture of neonatal hemochromatosis, with a remarkably elevated ferritin, that responded well to steroid therapy. CASE PRESENTATION An 8-day old full-term baby girl was referred to our center for evaluation of neonatal bradycardia and generalized jaundice that started in the first day of life. Prenatal history was significant for fetal bradycardia. Examination was unremarkable except for bradycardia and generalized jaundice. Laboratory findings included elevated alanine aminotransferase, aspartate aminotransferase, Alkaline Phosphatase, and total and direct bilirubin. Her ferritin was markedly elevated along with triglycerides. Sjogren syndrome antibodies were positive in addition to antinuclear and anti-smooth muscle antibodies. The diagnosis of cardiac neonatal lupus was given, and her liver disease was attributed to lupus despite the biochemical picture of neonatal hemochromatosis. She was started on oral prednisolone for which her liver function parameters showed a dramatic response and continued to be within the normal limits several weeks after discontinuation of steroids. CONCLUSION Neonatal lupus liver disease is a rare cause of neonatal cholestasis that can rarely present with neonatal hemochromatosis picture which unlike other causes of neonatal hemochromatosis can be reversed with steroid therapy.
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Affiliation(s)
- Ammar Abdulaziz Khayat
- Dpeartment of Pediatrics, College of Medicine, Umm Al Qura University, Al Abdeyah, Alawali, Makkah, 24381 Saudi Arabia
- Pediatric Gastroenterology Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Amani Jaboor Alkhaldi
- Pediatric Gastroenterology Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
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Chen W, Wang F, Zeng W, Zhang X, Shen L, Zhang Y, Zhou X. Biallelic mutations of TTC12 and TTC21B were identified in Chinese patients with multisystem ciliopathy syndromes. Hum Genomics 2022; 16:48. [PMID: 36273201 PMCID: PMC9587637 DOI: 10.1186/s40246-022-00421-z] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/12/2022] [Indexed: 12/04/2022] Open
Abstract
Background Abnormalities in cilia ultrastructure and function lead to a range of human phenotypes termed ciliopathies. Many tetratricopeptide repeat domain (TTC) family members have been reported to play critical roles in cilium organization and function.
Results Here, we describe five unrelated family trios with multisystem ciliopathy syndromes, including situs abnormality, complex congenital heart disease, nephronophthisis or neonatal cholestasis. Through whole-exome sequencing and Sanger sequencing confirmation, we identified compound heterozygous mutations of TTC12 and TTC21B in six affected individuals of Chinese origin. These nonsynonymous mutations affected highly conserved residues and were consistently predicted to be pathogenic. Furthermore, ex vivo cDNA amplification demonstrated that homozygous c.1464 + 2 T > C of TTC12 would cause a whole exon 16 skipping. Both mRNA and protein levels of TTC12 were significantly downregulated in the cells derived from the patient carrying TTC12 mutation c.1464 + 2 T > C by real-time qPCR and immunofluorescence assays when compared with two healthy controls. Transmission electron microscopy analysis further identified ultrastructural defects of the inner dynein arms in this patient. Finally, the effect of TTC12 deficiency on cardiac LR patterning was recapitulated by employing a morpholino-mediated knockdown of ttc12 in zebrafish. Conclusions To the best of our knowledge, this is the first study reporting the association between TTC12 variants and ciliopathies in a Chinese population. In addition to nephronophthisis and laterality defects, our findings demonstrated that TTC21B should also be considered a candidate gene for biliary ciliopathy, such as TTC26, which further expands the phenotypic spectrum of TTC21B deficiency in humans. Supplementary Information The online version contains supplementary material available at 10.1186/s40246-022-00421-z.
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Affiliation(s)
- Weicheng Chen
- Obstetrics and Gynecology Hospital of Fudan University, Pediatric Cardiovascular Center at Children's Hospital of Fudan University, Fudan University Shanghai Medical College, Shanghai, 200011, China
| | - Feifei Wang
- Obstetrics and Gynecology Hospital of Fudan University, Pediatric Cardiovascular Center at Children's Hospital of Fudan University, Fudan University Shanghai Medical College, Shanghai, 200011, China
| | - Weijia Zeng
- State Key Lab of Genetic Engineering, School of Life Sciences, Fudan University, Shanghai, 200438, China
| | - Xinyan Zhang
- Obstetrics and Gynecology Hospital of Fudan University, Pediatric Cardiovascular Center at Children's Hospital of Fudan University, Fudan University Shanghai Medical College, Shanghai, 200011, China
| | - Libing Shen
- International Human Phenome Institutes (IHPI), Shanghai, 200433, China
| | - Yuan Zhang
- Department of Assisted Reproduction, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 201204, China. .,, Shanghai, China.
| | - Xiangyu Zhou
- Obstetrics and Gynecology Hospital of Fudan University, Pediatric Cardiovascular Center at Children's Hospital of Fudan University, Fudan University Shanghai Medical College, Shanghai, 200011, China. .,Department of Assisted Reproduction, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 201204, China. .,, Shanghai, China.
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Abstract
Biliary atresia is a rare disease but remains the most common indication for pediatric liver transplantation as there are no effective medical therapies to slow progression after diagnosis. Variable contribution of genetic, immune, and environmental factors contributes to disease heterogeneity among patients with biliary atresia. Developing a deeper understanding of the disease mechanism will help to develop targeted medical therapies and improve patient outcomes.
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Affiliation(s)
- Swati Antala
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann and Robert H Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Sarah A. Taylor
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann and Robert H Lurie Children’s Hospital of Chicago, Chicago, IL, USA
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10
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Wang NL, Lin J, Chen L, Lu Y, Xie XB, Abuduxikuer K, Wang JS. Neonatal cholestasis is an early liver manifestation of children with acid sphingomyelinase deficiency. BMC Gastroenterol 2022; 22:227. [PMID: 35534800 PMCID: PMC9088046 DOI: 10.1186/s12876-022-02310-0] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/25/2022] [Indexed: 11/12/2022] Open
Abstract
Background Patients with acid sphingomyelinase deficiency (ASMD) may be referred to a hepatologist for liver manifestations. This study summarized the liver manifestations of patients with ASMD in the early disease course. Methods This study enrolled ASMD patients diagnosed by genetic tests between July 2016 and December 2020 in a national pediatric liver center. The significance of low High-density lipoprotein cholesterol (HDL-C) for aid diagnosis of ASMD in infancy was explored by reviewing 160 consecutive infants with liver manifestations, who underwent both genetic tests and lipid profile studies, between January 2020 and December 2020. Results A total of 7 patients were diagnosed as ASMD, and 10 known disease-causing variants were identified. Hepatosplenomegaly, elevated transaminases, and liver foam cells were observed in all the 7 patients at age ranging from 4 to 31 months. Low HDL-C was detected in 5 patients, cherry red spot in 4 patients, development delay in 3 patients, and interstitial lung diseases in 1 patient. Three ASMD patients developed cholestasis around 1 month of age, and bilirubin levels normalized at age ranging from 3 to 10 months. They had persistently elevated transaminases and hepatosplenomegaly, and died within 4 years of age. Among the 160 infants with liver manifestations, 125 (78.1%) had low HDL-C. Fifty-four had both low HDL-C and splenomegaly, including 48 cholestatic infants, but only 1 (1.9%, 1/54) infant without cholestasis was diagnosed as ASMD. Conclusions ASMD can manifest as neonatal cholestasis in the early disease course. Cholestasis is a pitfall when low HDL-C is used for aid diagnosis of ASMD in infants with splenomegaly.
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Affiliation(s)
- Neng-Li Wang
- Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Jing Lin
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lian Chen
- Department of Pathology, Children's Hospital of Fudan University, Shanghai, China
| | - Yi Lu
- Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Xin-Bao Xie
- Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, Shanghai, China
| | | | - Jian-She Wang
- Center for Pediatric Liver Diseases, Children's Hospital of Fudan University, Shanghai, China.
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11
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Wang H, Yang L, Wang J. Etiology of neonatal cholestasis after emerging molecular diagnostics. Transl Pediatr 2022; 11:359-367. [PMID: 35378957 PMCID: PMC8976681 DOI: 10.21037/tp-21-503] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 12/30/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In the pediatric group, most cholestatic patients had disease onset at 0-3 months of age, and more and more are found to have specific genetic defects after failing to obtain a definite diagnosis by routine evaluation. To investigate the etiological diagnosis for the newborns with cholestasis during the neonatal period after emerging molecular tests comprehensively. METHODS We conducted a retrospective study to evaluate clinical characteristics, etiologies and outcomes in infants with neonatal cholestasis after emerging molecular diagnostics from January 1st to December 31st, 2019 in Children's Hospital of Fudan University. RESULTS There were 160 cases of neonatal cholestasis with mean gestational age (GA) 32.6±4.8 weeks and birth weight (BW) 1,880±991 g, composing 3.4% of total neonatal admissions in 2019. Overall 97.5% (n=156) patients had a definite diagnosis, including 9 obtaining a genetic diagnosis after adding molecular test in routine evaluation, which made the diagnosis rate for cholestasis increased by 5.6%. The most common etiology of cholestasis in the neonatal period was parenteral nutrition-associated cholestasis (PNAC) 48.8% (n=78), followed by cardiovascular and circulatory disorders 18.1%, biliary anatomic obstruction 12.5%, infection 8.7% and genetic disorders 5.6%. PNAC and biliary anatomic obstruction were the most common etiology of cholestasis for preterm and term infants respectively. The mortality rate is 2.5% (n=4) and 91.9% (n=147) patients totally recovery or improve in follow-up. CONCLUSIONS The causes of cholestasis in neonates are complicated, molecular diagnostics can improve the etiological diagnosis for newborns with cholestasis. But still, quite amount of causes are remediable and transient during the neonatal period, gene test may help to rule out genetic causes and enhance confidence in judging prognosis.
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Affiliation(s)
- Huanhuan Wang
- Division of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Lin Yang
- Department of Endocrinology and Inherited Metabolic Diseases, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Jin Wang
- Division of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
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12
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Zhao D, Gong X, Li Y, Sun X, Chen Y, Deng Z, Zhang Y. Effects of cytomegalovirus infection on the differential diagnosis between biliary atresia and intrahepatic cholestasis in a Chinese large cohort study. Ann Hepatol 2022; 23:100286. [PMID: 33189910 DOI: 10.1016/j.aohep.2020.100286] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/24/2020] [Accepted: 11/02/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Differentiating biliary atresia from other causes of neonatal cholestasis is challenging, particularly when cytomegalovirus (CMV) and biliary atresia occur simultaneously. We aimed to elucidate whether CMV infection would affect the differential diagnosis of biliary atresia and intrahepatic cholestasis. PATIENTS AND METHODS This retrospective study was conducted among patients with neonatal cholestasis admitted to three tertiary hospitals between January 2010 and August 2019. The clinical characteristics, laboratory, and imaging findings were recorded. On the basis of the CMV serology results, the infants were classified into CMV-IgM (+) and CMV-IgM (-) groups. The clinical differences and diagnostic performances of routine predictors between biliary atresia and intrahepatic cholestasis were analyzed in each group. Finally, we compared the diagnostic performances of various tests in the two groups. RESULTS A total of 705 patients with neonatal cholestasis were enrolled: 215 (30.5%) patients were positive for CMV-IgM, among whom 97 had biliary atresia and 118 had CMV hepatitis; 490 infants were CMV-IgM (-), among whom 240 had biliary atresia and 250 had intrahepatic cholestasis. The diagnostic performances of stool color, direct bilirubin level, γ-glutamyl transpeptidase level, abnormal gallbladder, triangular cord sign, and hepatobiliary scintigraphy between CMV hepatitis and CMV-IgM (+) biliary atresia were similar to those between CMV-IgM (-) biliary atresia and CMV-IgM (-) intrahepatic cholestasis groups. CONCLUSIONS Our large-scale study showed a high prevalence of CMV infection in patients with neonatal cholestasis in China. The presence of CMV infection did not affect the routine predictors to discriminate biliary atresia and intrahepatic cholestasis.
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Affiliation(s)
- Dongying Zhao
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.
| | - Xiaohui Gong
- Department of Neonatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.
| | - Yahui Li
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.
| | - Xiaoang Sun
- Department of Pediatric Digestive Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Yan Chen
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.
| | - Zhaohui Deng
- Department of Pediatric Digestive Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Yongjun Zhang
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.
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13
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Behairy BES, Allam AAEH, Hegazy SG, Taie DM, Sira AM. Adequacy criteria of Tru-cut needle liver biopsy in neonatal cholestasis. Ann Hepatol 2021; 26:100548. [PMID: 34600141 DOI: 10.1016/j.aohep.2021.100548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/03/2021] [Accepted: 03/03/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Assessment of liver biopsy sample adequacy criteria is essential to avoid sampling errors in patients with diffuse liver pathology. Many studies have evaluated these criteria in adults; however, no previous studies have been performed on neonatal liver disorders. We aimed to assess the adequacy criteria of Tru-cut needle liver biopsy samples in infants with neonatal cholestasis (NC). METHODS In a retrospective analysis of infants who underwent liver biopsy for NC within a one-year duration, 58 specimens were recruited. The core lengths after fixation were measured. All samples were acquired with a 16-gauge (G) Tru-cut needle. Serial shortening of these samples was performed to define the smallest core length that gives representative parenchyma that could determine the activity grade and fibrosis stage reported by larger cores. RESULTS It was found that a 4-mm core length with a complete portal tract (CPT) number of 8±3 could adequately assess the NC activity grade. In addition, a 6-mm core length with a CPT number of 11±3 could adequately estimate NC fibrosis stage. CONCLUSIONS The adequacy criteria of liver tissue samples for the accurate assessment of NC are different from those defined for adult diffuse liver pathology. At least a 4-mm core length with a CPT number of 8±3 and a 6-mm core length with a CPT number of 11±3 acquired by a 16-G Tru-cut needle should be used to assess NC activity grade and fibrosis stage, respectively.
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Affiliation(s)
- Behairy El-Sayed Behairy
- Department of Pediatric Hepatology, Gastroenterology, and Nutrition, National Liver Institute, Menoufia University, 32511 Shebin El-Koom, Menoufia, Egypt
| | - Alif Abd El-Hakim Allam
- Department of Pediatric Hepatology, Gastroenterology, and Nutrition, National Liver Institute, Menoufia University, 32511 Shebin El-Koom, Menoufia, Egypt
| | - Shymaa Galal Hegazy
- Department of Pediatric Hepatology, Gastroenterology, and Nutrition, National Liver Institute, Menoufia University, 32511 Shebin El-Koom, Menoufia, Egypt
| | - Doha Maher Taie
- Department of Pathology, National Liver Institute, Menoufia University, 32511 Shebin El-Koom, Menoufia, Egypt
| | - Ahmad Mohamed Sira
- Department of Pediatric Hepatology, Gastroenterology, and Nutrition, National Liver Institute, Menoufia University, 32511 Shebin El-Koom, Menoufia, Egypt.
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14
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Czubkowski P, Thompson RJ, Jankowska I, Knisely AS, Finegold M, Parsons P, Cielecka-Kuszyk J, Strautnieks S, Pawłowska J, Bull LN. Progressive familial intrahepatic cholestasis — farnesoid X receptor deficiency due to NR1H4 mutation: A case report. World J Clin Cases 2021; 9:3631-3636. [PMID: 34046462 PMCID: PMC8130085 DOI: 10.12998/wjcc.v9.i15.3631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/16/2020] [Accepted: 02/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Functioning farnesoid X receptor (FXR; encoded by NR1H4) is key to normal bile acid homeostasis. Biallelic mutations in NR1H4 are reported in a few children with intrahepatic cholestasis. We describe a boy with progressive familial intrahepatic cholestasis and homozygous mutation in NR1H4.
CASE SUMMARY A boy had severe neonatal cholestasis with moderate hypercholanemia and persistently elevated alpha-fetoprotein. Despite medical treatment, coagulopathy was uncontrollable, prompting liver transplantation at age 8 mo with incidental splenectomy. The patient experienced catch-up growth with good liver function and did not develop allograft steatosis. However, 1 year after transplant, he died from an acute infection, considered secondary to immunosuppression and asplenia. A homozygous protein-truncating mutation, c.547C > T, p.(Arg183Ter), was subsequently identified in NR1H4, and both parents were shown to be heterozygous carriers. Absence of FXR and of bile salt export pump expression was confirmed by immunostaining of explanted liver.
CONCLUSION Severe cholestasis with persistently high alpha-fetoprotein and modest elevation of serum bile acid levels may suggest FXR deficiency. Some patients with FXR deficiency may not develop allograft steatosis and may respond well to liver transplantation.
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Affiliation(s)
- Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children’s Memorial Health Institute, Warsaw 04-730, Poland
| | - Richard J Thompson
- Institute of Liver Studies, King's College London Hospital, London SE5 9RS, United Kingdom
| | - Irena Jankowska
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children’s Memorial Health Institute, Warsaw 04-730, Poland
| | - A S Knisely
- Institut für Pathologie, Medizinische Universität Graz, Graz 8010, Austria
| | - Milton Finegold
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Pamela Parsons
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030, United States
- Texas Children’s Hospital, Houston, TX 77030, United States
| | - Joanna Cielecka-Kuszyk
- Department of Pathology, The Children’s Memorial Health Institute, Warsaw 04-730, Poland
| | - Sandra Strautnieks
- Institute of Liver Studies, King's College London Hospital, London SE5 9RS, United Kingdom
| | - Joanna Pawłowska
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children’s Memorial Health Institute, Warsaw 04-730, Poland
| | - Laura N Bull
- Department of Medicine and Institute for Human Genetics, UCSF Liver Center Laboratory, University of California San Francisco, San Francisco, CA 94143, United States
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15
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Santos Silva E, Moreira Silva H, Catarino C, Dias CC, Santos-Silva A, Lopes AI. Neonatal cholestasis: development of a diagnostic decision algorithm from multivariate predictive models. Eur J Pediatr 2021; 180:1477-1486. [PMID: 33410939 DOI: 10.1007/s00431-020-03886-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/06/2020] [Accepted: 11/20/2020] [Indexed: 11/28/2022]
Abstract
Despite the recent advances involving molecular studies, the neonatal cholestasis (NC) diagnosis still relays on the expertise of medical teams. Our aim was to develop models of etiological diagnosis and unfavourable prognosis which may support a rationale diagnostic approach. We retrospectively analysed 154 patients born between January 1985 and October 2019. The cohort was divided into two main groups: (A) transient cholestasis and (B) other diagnosis (with subgroups) and also in two groups of outcomes: (I) unfavourable and (II) favourable. Multivariate logistic regression analysis identified the lower gestational age as the only variable independently associated with an increased risk of transient cholestasis and signs and/or symptoms of sepsis with infectious or metabolic diseases. Gamma-glutamyl transferase serum levels > 300 IU/L had a positive predictive value for both diagnosis of biliary atresia and for alpha-1-antitrypsin deficiency (A1ATD) and for unfavourable prognosis. A model of diagnosis for A1ATD (n = 34) showed an area under the ROC curve = 0.843 [confidence interval (CI): 0.773-0.912].Conclusion: This study identified some predictors of diagnosis and prognosis which helped to build a diagnostic decision algorithm. The unusually large subgroup of patients with A1ATD in this cohort emphasizes its predictive diagnostic model. What Is Known • The etiological diagnosis of neonatal cholestasis (NC) requires a step-by-step guided approach, and diagnostic models have been developed only for biliary atresia. • Current algorithms neither address the epidemiology changes nor the application of the new molecular diagnostic tools. What Is New • This study provides diagnostic predictive models for patients with A1ATD, metabolic/infectious diseases, and transient cholestasis, and two models of unfavourable prognosis for NC. • A diagnostic decision algorithm is proposed based on this study, authors expertise and the literature.
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Affiliation(s)
- Ermelinda Santos Silva
- Gastroenterology Unit, Paediatrics Division, Child and Adolescent Department, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto, Largo da Maternidade, n° 45, 4050-651, Porto, Portugal. .,Integrated Master in Medicine, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313, Porto, Portugal. .,UCIBIO, REQUIMTE, Laboratory of Biochemistry, Department of Biological Sciences, Faculdade de Farmácia, Universidade do Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313, Porto, Portugal.
| | - Helena Moreira Silva
- Gastroenterology Unit, Paediatrics Division, Child and Adolescent Department, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto, Largo da Maternidade, n° 45, 4050-651, Porto, Portugal
| | - Cristina Catarino
- UCIBIO, REQUIMTE, Laboratory of Biochemistry, Department of Biological Sciences, Faculdade de Farmácia, Universidade do Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313, Porto, Portugal
| | - Cláudia Camila Dias
- MEDCIDS (Departamento de Medicina da Comunidade, Informação e Decisão em Saúde) and CINTESIS (Centro de Investigação em Tecnologias e em Serviços de Saúde), Faculdade de Medicina da Universidade do Porto, Rua Dr Plácido da Costa, s/n, 4200-450, Porto, Portugal
| | - Alice Santos-Silva
- UCIBIO, REQUIMTE, Laboratory of Biochemistry, Department of Biological Sciences, Faculdade de Farmácia, Universidade do Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313, Porto, Portugal
| | - Ana-Isabel Lopes
- Paediatric Gastroenterology Unit, Paediatrics Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Av. Prof. Egas Moniz, 1600-190, Lisboa, Portugal.,Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal
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16
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El-Araby HA, Saber MA, Radwan NM, Taie DM, Adawy NM, Sira AM. SOX9 in biliary atresia: New insight for fibrosis progression. Hepatobiliary Pancreat Dis Int 2021; 20:154-162. [PMID: 33349604 DOI: 10.1016/j.hbpd.2020.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 12/01/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Liver fibrosis is a hallmark determinant of morbidity in biliary atresia (BA) even in successfully operated cases. Responsible factors for this rapid progression of fibrosis are not completely defined. Aberrant expression of the transcription factor SOX9 and hepatic progenitor cells (HPCs) proliferation have roles in fibrogenesis in cholestatic disorders. However, they were not investigated sufficiently in BA. We aimed to delineate the relation of SOX9 and HPCs to fibrosis and its progression in BA. METHODS Forty-eight patients with BA who underwent an initial diagnostic liver biopsy (LB) and consequent intraoperative LB were recruited and compared to 28 cases with non-BA cholestasis that had an LB in their diagnostic workup. Liver fibrosis, tissue SOX9 and HPC expressions were studied in both BA and non-BA-cholestasis cases. Liver fibrosis, SOX9, and HPCs' dynamic changes in BA cases were assessed. Relation of fibrosis and its progression to SOX9 and HPCs in BA was assessed. RESULTS SOX9 and HPCs in ductular reaction (DR) form were expressed in 100% of BA and their grades increased significantly in the second biopsy. The rapidly progressive fibrosis in BA, represented by fibrosis grade of the intraoperative LB, correlated significantly to SOX9-DR and HPC-DR at the diagnostic (r = 0.420, P = 0.003 and r = 0.405, P = 0.004, respectively) and the intraoperative (r = 0.460, P = 0.001 and r = 0.467, P = 0.001, respectively) biopsy. On the other hand, fibrosis, SOX9-DR, and HPC-DR were significantly lower in non-BA cases at a comparable age (P < 0.001, P = 0.006, and P = 0.014, respectively). CONCLUSIONS Fibrosis in BA is rapidly progressive within a short time and is significantly correlated to SOX9 and HPCs. Assessment of targeting SOX9 and HPCs on fibrosis progression is warranted.
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Affiliation(s)
- Hanaa Ahmed El-Araby
- Department of Pediatric Hepatology, Gastroenterology, and Nutrition, National Liver Institute, Menoufia University, 32511 Shebin El-koom, Menoufia, Egypt
| | - Magdy Anwar Saber
- Department of Pediatric Hepatology, Gastroenterology, and Nutrition, National Liver Institute, Menoufia University, 32511 Shebin El-koom, Menoufia, Egypt
| | - Noha Mohamed Radwan
- Department of Pediatric Hepatology, Gastroenterology, and Nutrition, National Liver Institute, Menoufia University, 32511 Shebin El-koom, Menoufia, Egypt
| | - Doha Maher Taie
- Department of Pathology, National Liver Institute, Menoufia University, 32511 Shebin El-koom, Menoufia, Egypt
| | - Nermin Mohamed Adawy
- Department of Pediatric Hepatology, Gastroenterology, and Nutrition, National Liver Institute, Menoufia University, 32511 Shebin El-koom, Menoufia, Egypt
| | - Ahmad Mohamed Sira
- Department of Pediatric Hepatology, Gastroenterology, and Nutrition, National Liver Institute, Menoufia University, 32511 Shebin El-koom, Menoufia, Egypt.
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17
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Satomura Y, Bessho K, Kitaoka T, Takeyari S, Ohata Y, Kubota T, Ozono K. Neonatal cholestasis can be the first symptom of McCune–Albright syndrome: A case report. World J Clin Pediatr 2021; 10:7-14. [PMID: 33758748 PMCID: PMC7958557 DOI: 10.5409/wjcp.v10.i2.7] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/22/2021] [Accepted: 02/12/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND McCune–Albright syndrome (MAS) is caused by postzygotic somatic mutations of the GNAS gene. It is characterized by the clinical triad of fibrous dysplasia, café-au-lait skin spots, and endocrinological dysfunction. Myriad complications in MAS, including hepatobiliary manifestations, are also reported.
CASE SUMMARY This is a case of a 4-year-old boy who presented with MAS with neonatal cholestasis. He was suspected to have Alagille syndrome due to neonatal cholestasis with intrahepatic bile duct paucity in liver biopsy, peripheral pulmonary artery stenosis, and renal tubular dysfunction. By the age of 2 years, his cholestatic liver injury gradually improved, but he had repeated left femoral fractures. He did not exhibit endocrinological abnormality or café-au-lait skin spots. However, MAS was suspected due to fibrous dysplasia at the age of 4 years. No mutation was identified in the GNAS gene in the DNA isolated from the peripheral blood, but an activating point mutation (c.601C>T, p.Arg201Cys) was observed in the DNA extracted from the affected bone tissue and that extracted from the formalin-fixed paraffin-embedded liver tissue, which was obtained at the age of 1 mo.
CONCLUSION MAS should be considered as a differential diagnosis for transient cholestasis in infancy.
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Affiliation(s)
- Yoshinori Satomura
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Kazuhiko Bessho
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Taichi Kitaoka
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Shinji Takeyari
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Yasuhisa Ohata
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Takuo Kubota
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
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18
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Cho SJ, Perito ER, Shafizadeh N, Kim GE. Dialogs in the assessment of neonatal cholestatic liver disease. Hum Pathol 2021; 112:102-115. [PMID: 33359238 DOI: 10.1016/j.humpath.2020.12.007] [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: 10/21/2020] [Revised: 12/13/2020] [Accepted: 12/15/2020] [Indexed: 11/15/2022]
Abstract
Neonatal cholestatic liver disease is rarely encountered by pathologists outside of specialized pediatric centers and navigating the long list of potential diseases can be daunting. However, the differential diagnosis can be rapidly narrowed through open conversations between the pathologist and pediatric gastroenterologist. The dialog should ideally begin before obtaining the liver biopsy and continue through the rendering of the final pathologic diagnosis. Such dialogs are necessary to first ensure the proper handling of the precious sample and then to allow for synthesis of the clinical, laboratory, imaging, and genetic data in the context of the histologic features seen in the liver biopsy. In this review, we aim to provide a broad template on which such dialogs may be based and pitfalls that may be encountered on both the clinical and pathologic sides. This review will focus on non-biliary atresia etiologies of neonatal cholestasis, including select infectious, genetic, and metabolic entities.
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Affiliation(s)
- Soo-Jin Cho
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Emily R Perito
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, 94143, USA
| | | | - Grace E Kim
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA.
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19
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Becker PH, Demir Z, Mozer Glassberg Y, Sevin C, Habes D, Imbard A, Mussini C, Rozenfeld Bar Lev M, Davit-Spraul A, Benoist JF, Thérond P, Slama A, Jacquemin E, Gonzales E, Gaignard P. Adenosine kinase deficiency: Three new cases and diagnostic value of hypermethioninemia. Mol Genet Metab 2021; 132:38-43. [PMID: 33309011 DOI: 10.1016/j.ymgme.2020.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/22/2020] [Accepted: 11/22/2020] [Indexed: 12/13/2022]
Abstract
Adenosine kinase (ADK) deficiency is characterized by liver disease, dysmorphic features, epilepsy and developmental delay. This defect disrupts the adenosine/AMP futile cycle and interferes with the upstream methionine cycle. We report the clinical, histological and biochemical courses of three ADK children carrying two new mutations and presenting with neonatal cholestasis and neurological disorders. One of them died of liver failure whereas the other two recovered from their liver damage. As the phenotype was consistent with a mitochondrial disorder, we studied liver mitochondrial respiratory chain activities in two patients and revealed a combined defect of several complexes. In addition, we retrospectively analyzed methionine plasma concentration, a hallmark of ADK deficiency, in a cohort of children and showed that methionine level in patients with ADK deficiency was strongly increased compared with patients with other liver diseases. ADK deficiency is a cause of neonatal or early infantile liver disease that may mimic primary mitochondrial disorders. In this context, an elevation of methionine plasma levels over twice the upper limit should not be considered as a nonspecific finding. ADK deficiency induced-liver dysfunction is most often transient, but could be life-threatening.
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Affiliation(s)
- Pierre-Hadrien Becker
- Department of Biochemistry, Reference Center for Mitochondrial Disease, FILNEMUS, Bicêtre University Hospital, University of Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France; Lip(Sys)2, University of Paris-Saclay, Chatenay-Malabry, France
| | - Zeynep Demir
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, Reference Center for Mitochondrial Disease, FILNEMUS, Bicêtre University Hospital, University of Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Yael Mozer Glassberg
- Institute of Gastroenterology, Nutrition, and Liver Disease, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Caroline Sevin
- Pediatric Neurology Unit, Reference Center for Mitochondrial Disease, FILNEMUS, Bicêtre University Hospital, University of Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France; INSERM U1127, Institut du Cerveau et de la Moelle épinière (ICM), Pitié-Salpêtrière Hospital, Paris, France
| | - Dalila Habes
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, Reference Center for Mitochondrial Disease, FILNEMUS, Bicêtre University Hospital, University of Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Apolline Imbard
- Lip(Sys)2, University of Paris-Saclay, Chatenay-Malabry, France; Department of Metabolic Biochemistry, Necker Enfants Malades Hospital, University of Paris-Descartes, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Charlotte Mussini
- Department of Pathology, Bicêtre University Hospital, University of Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Michal Rozenfeld Bar Lev
- Institute of Gastroenterology, Nutrition, and Liver Disease, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Anne Davit-Spraul
- Department of Biochemistry, Reference Center for Mitochondrial Disease, FILNEMUS, Bicêtre University Hospital, University of Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France; Inserm U1193, Hepatinov, University Paris-Saclay, Orsay, France
| | - Jean-François Benoist
- Lip(Sys)2, University of Paris-Saclay, Chatenay-Malabry, France; Department of Metabolic Biochemistry, Necker Enfants Malades Hospital, University of Paris-Descartes, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Patrice Thérond
- Department of Biochemistry, Reference Center for Mitochondrial Disease, FILNEMUS, Bicêtre University Hospital, University of Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France; Lip(Sys)2, University of Paris-Saclay, Chatenay-Malabry, France
| | - Abdelhamid Slama
- Department of Biochemistry, Reference Center for Mitochondrial Disease, FILNEMUS, Bicêtre University Hospital, University of Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Emmanuel Jacquemin
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, Reference Center for Mitochondrial Disease, FILNEMUS, Bicêtre University Hospital, University of Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France; Inserm U1193, Hepatinov, University Paris-Saclay, Orsay, France
| | - Emmanuel Gonzales
- Pediatric Hepatology and Pediatric Liver Transplantation Unit, Reference Center for Mitochondrial Disease, FILNEMUS, Bicêtre University Hospital, University of Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France; Inserm U1193, Hepatinov, University Paris-Saclay, Orsay, France
| | - Pauline Gaignard
- Department of Biochemistry, Reference Center for Mitochondrial Disease, FILNEMUS, Bicêtre University Hospital, University of Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France; Lip(Sys)2, University of Paris-Saclay, Chatenay-Malabry, France.
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20
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Yachha SK, Das MC, Kumar P, Sharma L, Singh SK, Sen Sarma M, Kumar A, Srivastava A, Poddar U. Development of integrated neonatal cholestasis card for early recognition and referral of neonatal cholestasis. Indian J Gastroenterol 2020; 39:584-90. [PMID: 33175370 DOI: 10.1007/s12664-020-01094-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/08/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Delayed referral of neonatal cholestasis (NC) can result in significant morbidity and mortality. In this multi-center study, we aimed to evaluate the reliability of the stool card in the Indian population and develop an integrated NC card with (a) urine color identification and (b) stool color for early referral. METHODS Consecutive children with NC were enrolled and divided into two groups (biliary atresia [BA] and non-BA). Normal healthy children at 6-8 weeks of age served as controls. Each photograph of stool and urine samples of every child was evaluated by 6 parents, 6 paramedical staff, and 4 trainee doctors using a stool color card as a reference for stool samples. RESULTS Of 319 children (BA [n = 58], non-BA [n = 62], and controls [n = 199]), parents correctly detected dark yellow urine in all NC. Stool samples of 50 (86%) children with BA were unanimously labeled as pale by all observers. The average inter-item correlation showed good correlation between parents and trainee doctors of 0.77 and 0.64 with paramedical staff. CONCLUSION The integrated NC card proposes to recognize neonatal cholestasis at an early stage irrespective of etiology. It is a major step towards public health benefit both at the community as well as physicians' levels to enable early detection and timely referral and management.
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21
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Grünert SC, Schumann A, Freisinger P, Rosenbaum-Fabian S, Schmidts M, Mueller AJ, Beck-Wödl S, Haack TB, Schneider H, Fuchs H, Teufel U, Gramer G, Hannibal L, Spiekerkoetter U. Citrin deficiency mimicking mitochondrial depletion syndrome. BMC Pediatr 2020; 20:518. [PMID: 33176737 DOI: 10.1186/s12887-020-02409-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/30/2020] [Indexed: 11/10/2022] Open
Abstract
Background Neonatal intrahepatic cholestasis caused by citrin deficiency (CD) is a rare inborn error of metabolism due to variants in the SLC25A13 gene encoding the calcium-binding protein citrin. Citrin is an aspartate-glutamate carrier located within the inner mitochondrial membrane. Case presentation We report on two siblings of Romanian-Vietnamese ancestry with citrin deficiency. Patient 1 is a female who presented at age 8 weeks with cholestasis, elevated lactate levels and recurrent severe hypoglycemia. Diagnosis was made by whole exome sequencing and revealed compound heterozygosity for the frameshift variant c.852_855del, p.Met285Profs*2 and a novel deletion c.(69 + 1_70–1)_(212 + 1_231–1)del in SLC25A13. The girl responded well to dietary treatment with a lactose-free, MCT-enriched formula. Her younger brother (Patient 2) was born 1 year later and also found to be carrying the same gene variants. Dietary treatment from birth was able to completely prevent clinical manifestation until his current age of 4.5 months. Conclusions As CD is a well-treatable disorder it should be ruled out early in the differential diagnosis of neonatal cholestasis. Due to the combination of hepatopathy, lactic acidosis and recurrent hypoglycemia the clinical presentation of CD may resemble hepatic mitochondrial depletion syndrome.
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Izurieta Pacheco AC, Monfort Carretero L, Prat Torres C, García-Alix Pérez A, Molera Busoms C. NISCH syndrome: An extremely rare cause of neonatal cholestasis. J Hepatol 2020; 73:1257-1258. [PMID: 32863047 DOI: 10.1016/j.jhep.2020.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/06/2020] [Accepted: 07/06/2020] [Indexed: 12/04/2022]
Affiliation(s)
| | | | - Carolina Prat Torres
- Pediatric Dermatology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Alfredo García-Alix Pérez
- Institut de Recerca Sant Joan de Dèu, Hospital Sant Joan de Déu, NeNe Foundation, University of Barcelona, Barcelona, Spain
| | - Cristina Molera Busoms
- Pediatric Gastroenterology, Hepatology and Nutrition Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
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23
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Kim KY, Kim TH, Seong MW, Park SS, Moon JS, Ko JS. Mutation spectrum and biochemical features in infants with neonatal Dubin-Johnson syndrome. BMC Pediatr 2020; 20:369. [PMID: 32758197 PMCID: PMC7404915 DOI: 10.1186/s12887-020-02260-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 07/27/2020] [Indexed: 01/06/2023] Open
Abstract
Background Dubin-Johnson syndrome (DJS) is an autosomal recessive disorder presenting as isolated direct hyperbilirubinemia.DJS is rarely diagnosed in the neonatal period. The purpose of this study was to clarify the clinical features of neonatal DJS and to analyze the genetic mutation of adenosine triphosphate-binding cassette subfamily C member 2 (ABCC2). Methods From 2013 to 2018, 135 infants with neonatal cholestasis at Seoul National University Hospital were enrolled. Genetic analysis was performed by neonatal cholestasis gene panel. To clarify the characteristics of neonatal DJS, the clinical and laboratory results of 6 DJS infants and 129 infants with neonatal cholestasis from other causes were compared. Results A total of 8 different ABCC2 variants were identified among the 12 alleles of DJS. The most common variant was p.Arg768Trp (33.4%), followed by p.Arg100Ter (16.8%). Three novel variants were identified (p.Gly693Glu, p.Thr394Arg, and p.Asn718Ser). Aspartate transaminase (AST) and alanine transaminase (ALT) levels were significantly lower in infants with DJS than in infants with neonatal cholestasis from other causes. Direct bilirubin and total bilirubin were significantly higher in the infants with DJS. Conclusions We found three novel variants in 6 Korean infants with DJS. When AST and ALT levels are normal in infants with neonatal cholestasis, genetic analysis of ABCC2 permits an accurate diagnosis.
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Affiliation(s)
- Kwang Yeon Kim
- Department of Pediatrics, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-Gu, 110-769, Seoul, Korea
| | - Tae Hyeong Kim
- Department of Pediatrics, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-Gu, 110-769, Seoul, Korea
| | - Moon-Woo Seong
- Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Sup Park
- Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Soo Moon
- Department of Pediatrics, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-Gu, 110-769, Seoul, Korea
| | - Jae Sung Ko
- Department of Pediatrics, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-Gu, 110-769, Seoul, Korea.
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24
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Abstract
Neonatal cholestasis is characterized by conjugated hyperbilirubinemia in the newborn and young infant and is a sign common to over 100 hepatobiliary and/or metabolic disorders. A timely evaluation for its etiology is critical in order to quickly identify treatable causes such as biliary atresia, many of which benefit from early therapy. An expanding group of molecularly defined disorders involving bile formation, canalicular transporters, tight junction proteins and inborn errors of metabolism are being continuously discovered because of advances in genetic testing and bioinformatics. The advent of next generation sequencing has transformed our ability to test for multiple genes and whole exome or whole genome sequencing within days to weeks, enabling rapid and affordable molecular diagnosis for disorders that cannot be directly diagnosed from standard blood tests or liver biopsy. Thus, our diagnostic algorithms for neonatal cholestasis are undergoing transformation, moving genetic sequencing to earlier in the evaluation pathway once biliary atresia, "red flag" disorders and treatable disorders are excluded. Current therapies focus on promoting bile flow, reducing pruritus, ensuring optimal nutrition, and monitoring for complications, without addressing the underlying cause of cholestasis in most instances. Our improved understanding of bile formation and the enterohepatic circulation of bile acids has led to emerging therapies for cholestasis which require appropriate pediatric clinical trials. Despite these advances, the cause and optimal therapy for biliary atresia remain elusive. The goals of this review are to outline the etiologies, diagnostic pathways and current and emerging management strategies for neonatal cholestasis.
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Affiliation(s)
- Amy G. Feldman
- Pediatric Liver Center, Digestive Health Institute, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ronald J. Sokol
- Pediatric Liver Center, Digestive Health Institute, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colorado, USA,Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA,Corresponding Author: Ronald J. Sokol, Digestive Health Institute, Children’s Hospital Colorado, Box B290, 13123 E. 16th Ave., Aurora, Colorado, 80045, USA Phone: 720-777-6669, Fax: 720-777-7277,
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25
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Abstract
This issue of Seminars in Pediatric Surgery reviews leading topics in pediatric hepatobiliary surgery where controversy exists and provides a learning resource to the subject.
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Affiliation(s)
- Mark Davenport
- Department of Paediatric Surgery, Kings College Hospital, Denmark Hill, London SE5 9RS, UK.
| | - Mikko Pakarinen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University hospital, University of Helsinki, Finland
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26
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Lee MJ, Suh CR, Shin JH, Lee JH, Lee Y, Eun BL, Yoo KH, Shim JO. A Novel VPS33B Variant Identified by Exome Sequencing in a Patient with Arthrogryposis-Renal Dysfunction-Cholestasis Syndrome. Pediatr Gastroenterol Hepatol Nutr 2019; 22:581-587. [PMID: 31777725 PMCID: PMC6856508 DOI: 10.5223/pghn.2019.22.6.581] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/31/2019] [Indexed: 11/15/2022] Open
Abstract
Arthrogryposis-renal dysfunction-cholestasis (ARC) syndrome is a rare autosomal recessive multisystemic disease that is associated with the liver, kidney, skin, and central nervous and musculoskeletal systems. ARC occurs as a result of mutations in the VPS33B (Vacuolar protein sorting 33 homolog B) or VIPAR (VPS33B interacting protein, apical-basolateral polarity regulator) genes. A female infant presented with neonatal cholestasis with a severe clinical outcome. She was diagnosed with ARC syndrome using targeted exome sequencing (TES). Exome sequencing revealed compound heterozygous mutations, c.707A>T and c.239+5G>A, in VPS33B, where c.707A>T was a novel variant; the resultant functional protein defects were predicted via in silico analysis. c.239+5G>A, a pathogenic mutation that affects splicing, is found in less than 0.1% of the general population. Invasive techniques, such as liver biopsies, did not contribute to a differential diagnosis of ARC syndrome; thus, early TES together with clinical presentations constituted an apparently accurate diagnostic procedure.
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Affiliation(s)
- Min Ju Lee
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Chae Ri Suh
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Jeong Hee Shin
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Jee Hyun Lee
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Yoon Lee
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Baik-Lin Eun
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Kee Hwan Yoo
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Jung Ok Shim
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
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27
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Abstract
Hyperbilirubinemia is a common occurrence in neonates; it may be physiological or pathological. Conjugated hyperbilirubinemia may result from medical or surgical causes, and can result in irreversible liver damage if untreated. The aim of imaging is the timely diagnosis of surgical conditions like biliary atresia and choledochal cysts. Abdominal ultrasound is the first line imaging modality, and Magnetic resonance cholangiopancreatography (MRCP) also has a role, especially in pre-operative assessment of choledochal cysts (CDCs). For biliary atresia, the triangular cord sign and gallbladder abnormalities are the two most useful ultrasound features, with a combined sensitivity of 95%. Liver biopsy has an important role in pre-operative evaluation; however, the gold standard for diagnosis of biliary atresia remains an intra-operative cholangiogram. Choledochal cysts are classified into types according to the number, location, extent and morphology of the areas of cystic dilatation. They are often associated with an abnormal pancreaticobiliary junction, which is best assessed on MRCP. Caroli's disease or type 5 CDC comprises of multiple intrahepatic cysts. CDCs, though benign, require surgery as they may be associated with complications like cholelithiasis, cholangitis and development of malignancy. Severe unconjugated hyperbilirubinemia puts neonates at high risk of developing bilirubin induced brain injury, which may be acute or chronic. Magnetic resonance imaging of the brain is the preferred modality for evaluation, and shows characteristic involvement of the globus pallidi, subthalamic nuclei and cerebellum - in acute cases, these areas show T1 hyperintensity, while chronic cases typically show hyperintensity on T2 weighted images.
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28
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Abstract
Navigating the complexities of interpreting a liver biopsy performed on a neonate with conjugated/direct hyperbilirubinemia can be an arduous task given these biopsies are infrequently encountered. The list of entities is long and yet there are only a few histologic patterns of liver injury. The first step for the pathologist is to determine the histologic pattern, which will guide further inquiry into the useful clinical information to have while evaluating the biopsy. Ultimately, the goal is to identify those conditions that will benefit from early intervention. We begin with a review of biliary development to help understand what findings may be physiologic versus pathologic, particularly in premature infants. Then we review eight cases that cover the three most common histologic patterns of injury in patients with neonatal cholestasis: biliary obstructive, neonatal hepatitis, and paucity of intrahepatic bile ducts. The entities that serve as prototypes for these histologic patterns are covered, including biliary atresia, idiopathic neonatal hepatitis, and Alagille syndrome, along with rarer entities that have histologic overlap. The cases with accompanying tables and algorithms are intended to help place the histologic findings in the context of the overall clinical work-up, including genetic testing.
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Affiliation(s)
- Soo-Jin Cho
- Department of Pathology, University of California San Francisco, San Francisco, CA United States
| | - Grace E Kim
- Department of Pathology, University of California San Francisco, San Francisco, CA United States.
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29
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Ramachandran P, Balamurali D, Peter JJ, Kumar MM, Safwan M, Vij M, Rela M, Mahalingam S. RNA-seq reveals outcome-specific gene expression of MMP7 and PCK1 in biliary atresia. Mol Biol Rep 2019; 46:5123-30. [PMID: 31342296 DOI: 10.1007/s11033-019-04969-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/04/2019] [Indexed: 12/25/2022]
Abstract
The disease phenotype in biliary atresia (BA) is caused by a fibro-inflammatory process leading to destruction of cholangiocytes, obstruction of ductular pathways and eventual progression to liver cirrhosis. The first line of management is a Kasai portoenterostomy (KPE) followed by liver transplantation (LT) in some children. Several factors have been postulated to affect the outcome of KPE and/or the subsequent progression of liver disease. However, no biomarkers have been identified in the liver for BA. We aimed to address this deficit. Whole transcriptome mRNA sequencing was performed for 29 samples (25 BA and 4 Controls) to identify the candidate genes predicting the prognosis of KPE. These results were further confirmed with quantitative Realtime PCR (qPCR). Analysis from RNA-sequencing data identified matrix metalloproteinase7 (MMP7) and phosphoenolpyruvate carboxykinase (PCK1) as potential determinants of the outcome of KPE. MMP7 expression was significantly elevated in patients who failed to clear jaundice after KPE as well as in patients with End Stage Liver Disease (ESLD). In contrast, PCK1 level was upregulated in patients who had successful KPE, while there was a significant down regulation in patients who failed KPE. MMP7 and PCK1 expression patterns had an inverse relation to the outcome of KPE and hence could potentially be used as biomarkers to predict KPE outcome and disease progression, enabling clinicians to design new treatment strategies for BA.
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30
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Abstract
Background Clinical diagnosis of neonatal cholestasis is considered to be an extremely challenging process. Here we highlight the importance not only of the prompt distinction between extrahepatic and intrahepatic cholestasis forms, but also of the precise identification of the latter ones amongst the hotchpotch of recently discovered metabolic/genetic causes. Biliary atresia is considered a surgical emergency in a newborn infant. The rate of success in establishing the bile drainage is in fact a function of the early age when the hepato-portoenterostomy intervention is performed. Intrahepatic cholestasis is due to a broad and more and more puzzling variety of infectious, endocrine, genetic, metabolic and toxic disorders where Gamma-glutamyl transpeptidase serum levels may help for differential diagnosis. Recently established laboratory diagnostic techniques have allowed to discover new causes of neonatal cholestasis. Aim of the Commentary is to go through some of them and bring the focus particularly on the information deriving from the paper by Pinon et al. in this issue of the Journal, which paves the way to the inclusion of the hepatocyte nuclear factor-1-beta deficiency as a new condition to consider in the diagnostic process of the syndromic forms with paucity of intralobular bile ducts. Conclusion Neonatal cholestasis poses diagnostic challenges in practice. Recent advances in the pathophysiology and in molecular genetics together with clinical features, histopathologic findings and careful reasoning remains paramount to put together the pieces of the jigsaw.
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Affiliation(s)
- Claudia Mandato
- Department of Pediatrics, Children's Hospital Santobono-Pausilipon, 80129, Naples, Italy
| | - Giada Zollo
- Pediatrics Section, University of Salerno -Baronissi Campus - Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, 84081, Baronissi, Salerno, Italy
| | - Pietro Vajro
- Pediatrics Section, University of Salerno -Baronissi Campus - Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, 84081, Baronissi, Salerno, Italy.
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31
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Moreira-Silva H, Maio I, Bandeira A, Gomes-Martins E, Santos-Silva E. Metabolic liver diseases presenting with neonatal cholestasis: at the crossroad between old and new paradigms. Eur J Pediatr 2019; 178:515-523. [PMID: 30693370 DOI: 10.1007/s00431-019-03328-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 11/14/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 12/18/2022]
Abstract
Metabolic liver diseases (MLD) are an important group of disorders presenting with neonatal cholestasis (NC). The spectrum of liver involvement is wide and the presumptive diagnosis is traditionally based on clinical and laboratory findings. Recently, next-generation sequencing (NGS) panels have emerged as an appealing tool to diagnose neonatal/infantile cholestatic disorders. The aim of this study was to identify clinical phenotypes of liver injury and contribute to find a diagnostic methodology that integrates new molecular diagnostic tools. We retrospectively analyzed the clinical and biochemical features of 16 patients with MLD and NC. Patients were categorized into three groups: A-NC with liver failure (N = 8): tyrosinemia type I (n = 2), classic galactosemia (n = 5), mitochondrial DNA depletion syndrome (n = 1); B-NC evolving with chronic liver disease (N = 5): argininemia (n = 2); mitochondrial cytopathy (n = 1); congenital disorders of glycosylation type Ia (n = 1); Zellweger syndrome (n = 1); and C-transient NC (N = 3): Niemann-Pick type C (n = 2), citrullinemia type II (n = 1).Conclusion: MLD presenting with NC can be categorized into three main clinical phenotypes of liver injury. We highlight transient NC as a clue for MLD that must be pursued. New molecular diagnostic tools can play a key role, but application criteria must be established to make them cost-effective. What is Known: • Metabolic liver diseases are an important group of disorders presenting with neonatal cholestasis. • The diagnostic approach is challenging and traditionally based on clinical and laboratory findings. Next-generation sequencing is a recent and rapidly developing tool in pediatric hepatology. What is New: • We provide a liver-targeted characterization of metabolic liver diseases presenting with neonatal cholestasis, categorizing them into three clinical phenotypes that may narrow the diagnostic possibilities. • A clinical decision-making algorithm is proposed, in which the NGS technology is integrated.
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Affiliation(s)
- Helena Moreira-Silva
- Pediatric Gastroenterology Unit, Centro Materno Infantil do Norte - CMIN, Centro Hospitalar Universitário do Porto, Largo da Maternidade de Júlio Dinis, 4050-651, Porto, Portugal
| | - Inês Maio
- Pediatric Gastroenterology Unit, Centro Materno Infantil do Norte - CMIN, Centro Hospitalar Universitário do Porto, Largo da Maternidade de Júlio Dinis, 4050-651, Porto, Portugal
| | - Anabela Bandeira
- Pediatric Metabolic Unit, Centro Materno Infantil do Norte - CMIN, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Esmeralda Gomes-Martins
- Pediatric Metabolic Unit, Centro Materno Infantil do Norte - CMIN, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | - Ermelinda Santos-Silva
- Pediatric Gastroenterology Unit, Centro Materno Infantil do Norte - CMIN, Centro Hospitalar Universitário do Porto, Largo da Maternidade de Júlio Dinis, 4050-651, Porto, Portugal. .,Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal.
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32
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Abstract
Inborn errors of bile acid metabolism are rare causes of neonatal cholestasis and liver disease in older children and adults. The diagnosis should be considered in the context of hyperbilirubinemia with normal serum bile acids and made by urinary liquid secondary ionization mass spectrometry or DNA testing. Cholic acid is an effective treatment of most single-enzyme defects and patients with Zellweger spectrum disorder with liver disease.
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Affiliation(s)
- James E Heubi
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA; Division of Pathology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA.
| | - Kenneth D R Setchell
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA; Division of Pathology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA
| | - Kevin E Bove
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA; Division of Pathology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 240 Sabin Way, Cincinnati, OH 45229, USA
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33
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Fujishiro J, Suzuki K, Watanabe M, Uotani C, Takezoe T, Takamoto N, Hayashi K. Outcomes of Alagille syndrome following the Kasai operation: a systematic review and meta-analysis. Pediatr Surg Int 2018; 34:1073-1077. [PMID: 30073479 DOI: 10.1007/s00383-018-4316-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE Infants with Alagille syndrome (AGS) frequently develop neonatal cholestasis, and some AGS infants who suspected of biliary atresia subsequently undergo the Kasai operation with the diagnosis of biliary atresia. The aim of this study was to investigate the effect of the Kasai operation on liver and patient outcomes among AGS patients, using a meta-analysis. METHODS A systematic review and meta-analysis of studies describing the outcomes of AGS patients with/without the Kasai operation were conducted. The analyzed outcomes were liver transplantation, not living with the native liver, and mortality for any reason. RESULTS We identified 6 studies (394 AGS patients). All studies were retrospective cohort or case-control studies. The incidences of liver transplantation, not living with the native liver, and mortality were significantly higher in AGS patients who underwent the Kasai operation than in those who did not undergo the Kasai operation (odds ratio: 6.46, 95% CI 3.23-12.89, p < 0.00001; odds ratio: 25.88, 95% CI 2.83-236.84, p < 0.004; odds ratio: 15.05, 95% CI 2.70-83.93, p = 0.002, respectively). CONCLUSION The Kasai operation was associated with poor outcomes in AGS patients. It remains unclear if the Kasai operation directly deteriorates liver and patient outcomes in AGS patients.
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Affiliation(s)
- Jun Fujishiro
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Kan Suzuki
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Miho Watanabe
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Chizue Uotani
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toshiko Takezoe
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Naohiro Takamoto
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kentaro Hayashi
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Santos Silva E, Klaudel-Dreszler M, Bakuła A, Oliva T, Sousa T, Fernandes PC, Tylki-Szymańska A, Kamenets E, Martins E, Socha P. Early onset lysosomal acid lipase deficiency presenting as secondary hemophagocytic lymphohistiocytosis: Two infants treated with sebelipase alfa. Clin Res Hepatol Gastroenterol 2018; 42:e77-e82. [PMID: 29705274 DOI: 10.1016/j.clinre.2018.03.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 02/03/2018] [Accepted: 03/21/2018] [Indexed: 02/04/2023]
Abstract
Two unrelated infants were diagnosed with and initially treated for hemophagocytic lymphohistiocytosis (HLH), but progressed to cholestasis and liver failure. Early onset lysosomal acid lipase deficiency (EO-LAL-D) was suspected due to lymphocytes with cytoplasmic vacuolation and/or adrenal calcifications and confirmed by enzymatic and genetic analysis. Enzyme replacement therapy with sebelipase alfa was implemented, but both children died, despite initial improvement. Since this inborn error of metabolism progresses rapidly in infants, early diagnosis is crucial, and appropriate treatment should be started as soon as possible. The authors suggest that the diagnosis of EO-LAL-D should be considered in infants with symptoms of HLH.
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Affiliation(s)
- Ermelinda Santos Silva
- Gastroenterology unit, Pediatrics Division, Child and Adolescent Department, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto, Largo da Maternidade, 4050-651 Porto, Portugal; Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal.
| | - Maja Klaudel-Dreszler
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Paediatrics, Children's Memorial Health Institute, Warsaw, Poland.
| | - Agnieska Bakuła
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Paediatrics, Children's Memorial Health Institute, Warsaw, Poland.
| | - Teresa Oliva
- Pediatrics Division, Instituto Português de Oncologia do Porto, Portugal.
| | - Tereza Sousa
- Laboratorial Hematology Division, Instituto Português de Oncologia, Porto, Portugal.
| | - Paula Cristina Fernandes
- Pediatric Intensive Care Division, Child and Adolescent Department, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto, Portugal.
| | - Anna Tylki-Szymańska
- Department of Paediatrics, Nutrition and Metabolic Disorders, Children's Memorial Health Institute, Warsaw, Poland.
| | | | - Esmeralda Martins
- Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal; Metabolic Diseases Unit, Pediatrics Division, Child and Adolescent Department, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto, Portugal.
| | - Piotr Socha
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Paediatrics, Children's Memorial Health Institute, Warsaw, Poland.
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Zhou S, Wang Z, He F, Qiu H, Wang Y, Wang H, Zhou J, Zhou J, Cheng G, Zhou W, Xu R, Wang M. Association of serum bilirubin in newborns affected by jaundice with gut microbiota dysbiosis. J Nutr Biochem 2018; 63:54-61. [PMID: 30342317 DOI: 10.1016/j.jnutbio.2018.09.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 09/10/2018] [Accepted: 09/12/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS Breast milk jaundice (BMJ) is common and benign, but neonatal cholestasis (NC) is rare and not benign, so early differentiation between NC and non-NC jaundice is important and may facilitate diagnosis and treatment. Gut microbiota plays an important role in enterohepatic circulation, which in turn plays an important role in the secretion of bilirubin. We aimed to determine the composition of gut microbiota in patients with NC and BMJ, and to identify the gut microbiota composition associated with NC and BMJ. METHODS Data on age, gender, delivery, feeding mode, serum total bilirubin, direct bilirubin, and liver function were collected for NC patients, BMJ patients and healthy controls, respectively. Shotgun metagenomic sequencing and metagenome-wide association were performed. RESULTS Forty NC patients, 16 patients affected by BMJ, and 14 healthy controls (CON) without jaundice were enrolled. A significant increase in species richness, especially Bacteroides, was found in NC patients. The abundances of potentially pathogenic species and KEGG orthologies (KOs) of virulence factor genes were positively correlated with serum bilirubin level. The abundances of nine species of Bifidobacterium and three KOs of galactose metabolism were significantly decreased in the jaundice group (NC and BMJ) and were negatively correlated with serum bilirubin level. CONCLUSIONS The gut microbiota in NC patients is characterized by a significant increase in species richness, possibly due to the proliferation of potentially pathogenic species. Additionally, the gut microbiota in jaundice patients is characterized by a decreased abundance of Bifidobacterium. Decreased Bifidobacterium has been associated with elevated bilirubin and abnormal gut microbiota galactose metabolic pathway. Further, ten bacteria species were identified as potential biomarker of jaundice. KEY POINTS Question Is there any alteration of gut microbiotain neonatal cholestasis patients? Does gut microbiota have any involvement in the occurrence of neonatal cholestasis or breast milk jaundice? Findings The alteration of gut microbiota in neonatal cholestasis patients mainly manifested as a significant increase in species richness and an increased abundance of potentially pathogenic species, while the main manifestation in jaundice patients was a significant decrease in Bifidobacterium which may be involved in the metabolism of bilirubin through the galactose metabolic pathway. Meaning The results suggest that an imbalance of gut microbiota exist in neonatal cholestasis and breast milk jaundice patients, primarily in the form of a substantial reduction in the abundance of Bifidobacterium, suggesting the possibility of intervention treatment for neonatal cholestasis and breast milk jaundice by supplementing probiotics.
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Affiliation(s)
- Shaoming Zhou
- Division of Gastroenterology, Shenzhen Children's Hospital, Shenzhen, Guangdong, 518038, China.
| | - Zhangxing Wang
- Division of Neonatology, Shenzhen Longhua People's Hospital, Guangdong, 518109, China
| | - Fusheng He
- Imunobio, Shenzhen, Guangdong, China, 518001
| | - Huixian Qiu
- Division of Neonatology, Longgang Central Hospital of Shenzhen, Guangdong, 518116, China
| | - Yan Wang
- Imunobio, Shenzhen, Guangdong, China, 518001
| | - Huihui Wang
- Division of Clinical Nutrition, Shenzhen Children's Hospital, Shenzhen, Guangdong, 518038, China
| | - Jianli Zhou
- Division of Gastroenterology, Shenzhen Children's Hospital, Shenzhen, Guangdong, 518038, China
| | - Jiaxiu Zhou
- Division of Psychology, Shenzhen Children's Hospital, Shenzhen, Guangdong, 518038, China
| | - Guoqiang Cheng
- Division of Neonatology, Children's Hospital of Fudan University, National Center for Children's Health, Shanghai, 201102, China
| | - Wenhao Zhou
- Division of Neonatology, Children's Hospital of Fudan University, National Center for Children's Health, Shanghai, 201102, China
| | - Ruihuan Xu
- Clinical Laboratory, Longgang Central Hospital of Shenzhen, Guangdong, 518116, China.
| | - Mingbang Wang
- Xiamen Branch, Shanghai Key Laboratory of Birth Defects, Division of Neonatology, Children's Hospital of Fudan University, National Center for Children's Health, Shanghai, 201102, China.
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Dong R, Jiang J, Zhang S, Shen Z, Chen G, Huang Y, Zheng Y, Zheng S. Development and Validation of Novel Diagnostic Models for Biliary Atresia in a Large Cohort of Chinese Patients. EBioMedicine 2018; 34:223-30. [PMID: 30077722 DOI: 10.1016/j.ebiom.2018.07.025] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [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: 05/22/2018] [Revised: 07/06/2018] [Accepted: 07/17/2018] [Indexed: 02/07/2023] Open
Abstract
Background & aims The overlapping features of biliary atresia (BA) and the other forms of neonatal cholestasis (NC) with different causes (non-BA) has posed challenges for the diagnosis of BA. This study aimed at developing new and better diagnostic models for BA. Methods We retrospectively analyzed data from 1728 newborn infants with neonatal obstructive jaundice (NOJ). New prediction models, including decision tree (DT), random forest (RF), and multivariate logistic regression-based nomogram for BA were created and externally validated in an independent set of 508 infant patients. Results Fiver predictors, including gender, weight, direct bilirubin (DB), alkaline phosphatase (ALP), and gamma-glutamyl transpeptidase (GGT) were significantly different between the BA and non-BA groups (P < .05), from which DT, RF, and nomogram models were developed. The area under the receiver operating characteristic (ROC) curve (AUC) value for the nomogram was 0.898, which was greater than that of a single biomarker in the prediction of BA. Performance comparison of the three diagnostic models showed that the nomogram displayed better discriminative ability (sensitivity, 85.7%; specificity, 80.3%; PPV, 0.969) at the optimal cut-off value compared with DT and RF, which had relatively similar high sensitivity and PPV (0.941 and 0.947, respectively), but low specificity in the modeling group. In sub-analysis of the discriminative capacity between the nomogram and GGT (<300 or ≥ 300), we found that the nomogram was superior to the GGT alone in the preoperative diagnosis of BA. Conclusions The nomogram has demonstrated better performance for the prediction of BA, holding promise for future clinical application. A novel nomogram has been established for prediction of biliary atresia (BA). Its discriminatory ability is significantly improved compared with GGT alone. It holds promise for clinical application for better diagnosis of BA.
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Abstract
The inherited diseases causing conjugated hyperbilirubinemia are diverse, with variability in clinical severity, histologic appearance, and time of onset. The liver biopsy appearances can also vary depending on whether the initial presentation is in the neonatal period or later. Although many of the disorders have specific histologic features in fully developed and classic cases, biopsies taken early in the disease course may be nonspecific, showing either cholestatic hepatitis or an obstructive pattern of injury requiring close correlation with the laboratory and clinical findings to reach the correct diagnosis. Additionally, increased understanding of the range of hepatic changes occurring in mild deficiencies of bile canalicular transporter proteins suggest that these disorders, particularly ABCB4 deficiency, may be more common than previously recognized; improved awareness should prompt further investigation.
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Affiliation(s)
- Andrew D Clouston
- Faculty of Medicine, University of Queensland, Herston Road, Brisbane, Queensland 4006, Australia.
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Amil Dias J. Biliary Atresia - Too Few, Too Many Centers. GE Port J Gastroenterol 2018; 25:57-58. [PMID: 29662927 PMCID: PMC5892320 DOI: 10.1159/000484352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 10/13/2017] [Indexed: 06/08/2023]
Affiliation(s)
- Jorge Amil Dias
- *Dr. Jorge Amil Dias, Unidade de Gastrenterologia Pediátrica, Centro Hospitalar S. João, Alameda Professor Hernãni Monteiro, PT-4202-451 Porto (Portugal), E-Mail
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Abstract
Biliary atresia is a devastating biliary disease of neonates that results in liver transplantation for the vast majority. The etiology of biliary atresia is unknown and is likely multifactorial, with components of genetic predisposition, environmental trigger and autoimmunity contributing to disease pathogenesis. This review highlights recent work related to investigations of disease pathogenesis in biliary atresia.
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Affiliation(s)
- Alexandra Kilgore
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Digestive Health Institute, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Cara L. Mack
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Digestive Health Institute, Children’s Hospital Colorado, Aurora, CO 80045, USA
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Mandelia A, Lal R, Mutt N. Role of Hepatobiliary Scintigraphy and Preoperative Liver Biopsy for Exclusion of Biliary Atresia in Neonatal Cholestasis Syndrome. Indian J Pediatr 2017; 84:685-690. [PMID: 28687948 DOI: 10.1007/s12098-017-2408-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 06/07/2017] [Indexed: 10/19/2022]
Abstract
All diagnostic algorithms for Neonatal Cholestasis Syndrome (NCS) focus on differentiating numerous medical causes from Biliary Atresia (BA). No preoperative diagnostic algorithm has 100% diagnostic accuracy for BA and yet, timely diagnosis is crucial to optimize surgical outcome. Markers for high index of clinical suspicion for BA are: a "usually" well thriving infant with conjugated hyperbilirubinemia, raised gamma glutamyl transpeptidase, persistently "acholic" stools, firm hepatomegaly with dysmorphic, hypoplastic gall bladder. In the presence of above 'red flag' signs, there has been much debate on diagnostic accuracy of percutaneous liver biopsy (PLB) vs. hepatobiliary scintigraphy (HBS) to substantiate or exclude BA. Recent guidelines suggest a shift towards PLB (91.6% overall diagnostic accuracy) as the diagnostic cornerstone with key differentiating feature being 'bile ductular proliferation'. HBS has a high (98.7%) sensitivity but low specificity (37-74%) with an overall diagnostic accuracy of 67% for BA. Severe hepatocellular disease without anatomic obstruction would also have a non-excretory scan. Thus, while excretory HBS excludes BA, non-excretion does not confirm BA. Hence, diagnostic algorithms relying on non-excretory HBS as the primary standalone benchmark for surgical exploration would be mired by a high negative laparotomy rate revealing a normal peroperative cholangiogram (POC). However, an excretory HBS obviates need for laparotomy in case of equivocal stool color or PLB. A POC continues to be the ultimate gold standard. Hence, with high index of clinical suspicion but equivocal ultrasonography or PLB and a non-excretory HBS, the baby should not be denied a POC within time frame crucial for successful hepatoportoenterostomy.
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Affiliation(s)
- Ankur Mandelia
- Department of Pediatric Surgical Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Richa Lal
- Department of Pediatric Surgical Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India.
| | - Nijagal Mutt
- Department of Pediatric Surgical Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
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Mathiyazhagan G, Jagadisan B. Referral Patterns and Factors Influencing Age at Admission of Infants with Cholestasis in India. Indian J Pediatr 2017; 84:591-596. [PMID: 28397065 DOI: 10.1007/s12098-017-2342-0] [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: 11/07/2016] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To define the recognition, age at admission, referral time and referral pattern of neonatal cholestasis in India. METHODS This prospective, observational study was conducted from February 2015 through March 2016 in the Pediatric gastroenterology unit of JIPMER, Pondicherry in infants with cholestasis < 6 mo of age. RESULTS Among 64 infants, median age of admission was 52 d (IQR 28-63 d). Fifty of sixty four infants (78.1%) came with parent-reported cholestasis-related symptoms of either jaundice alone (57.8%) or bleeding manifestations (20.3%). In 21.9% infants, jaundice was detected by physicians at a median age of 45 d (IQR 38.5-53.2 d). Two infants had intracranial bleed. Only 34% infants with pale stools were identified by the mother. The median healthcare-seeking time was 5.5 d (IQR 2.5-12 d). Among infants presenting to primary healthcare physicians (PHPs) with cholestasis-related symptoms, median time to referral was 5 d (IQR 2.5-12 d). The first point of healthcare contact in 54.7% was a PHP; 17.1% PHPs had reassured the parents. Herbal preparations were prescribed by 14.3%. Only 11.8% of those with jaundice as the only problem were given vitamin K before referral. Biliary atresia (BA) was missed in neonatal intensive care units in 9 cases. CONCLUSIONS The above issues need to be accounted for before evaluating or implementing screening strategies in India.
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Affiliation(s)
- Gopinathan Mathiyazhagan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Pondicherry, 605006, India
| | - Barath Jagadisan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Pondicherry, 605006, India.
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Abstract
Neonatal jaundice is common and usually not concerning when it is secondary to unconjugated hyperbilirubinemia, below the neurotoxic level, and resolves early. Primary care providers should be vigilant, however, about evaluating infants in whom jaundice presents early, is prolonged beyond 2 weeks of life, or presents at high levels. Even in well-appearing infants, fractionated (direct and indirect) bilirubin levels should be obtained in these clinical scenarios to evaluate for potential cholestasis. This review presents an approach to the evaluation of a jaundiced infant and discusses diagnosis and management of several causes of neonatal cholestasis.
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Affiliation(s)
- Erin Lane
- Division of Gastroenterology, Seattle Children's Hospital, 4800 Sand Point Way Northeast, M/S OB 9.620, PO Box 50020, Seattle, WA 98115, USA
| | - Karen F Murray
- Division of Gastroenterology, Seattle Children's Hospital, 4800 Sand Point Way Northeast, M/S OB 9.620, PO Box 50020, Seattle, WA 98115, USA.
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Pereira NMD, Shah I. Neonatal cholestasis mimicking biliary atresia: Could it be urinary tract infection? SAGE Open Med Case Rep 2017; 5:2050313X17695998. [PMID: 28321310 PMCID: PMC5347411 DOI: 10.1177/2050313x17695998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 02/02/2017] [Indexed: 11/16/2022] Open
Abstract
Cholestasis can occur in newborns due to infections. However, the manifestations of the underlying infections usually dominate the presentation. We present a 2-month-old infant who presented with jaundice and no fever or signs of systemic illness. Liver biopsy was suggestive of cholangitis. He was subsequently detected to have urinary tract infection with Klebsiella pneumoniae. The child was treated with appropriate antibiotics for 2 weeks following which the cholestasis resolved. Thus, neonatal cholestasis due to infections can also occur in the post-neonatal period without clinical manifestations of an underlying infection.
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Affiliation(s)
| | - Ira Shah
- Department of Pediatrics, Bai Jerbai Wadia Hospital for Children, Mumbai, India
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Santos Silva E, Moreira Silva H, Azevedo Lijnzaat L, Melo C, Costa E, Martins E, Lopes AI. Clinical practices among healthcare professionals concerning neonatal jaundice and pale stools. Eur J Pediatr 2017; 176:361-369. [PMID: 28083674 DOI: 10.1007/s00431-016-2847-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 12/25/2016] [Accepted: 12/29/2016] [Indexed: 01/23/2023]
Abstract
UNLABELLED Jaundice and pale stools are major indicators of neonatal liver disease. Prognosis depends on timely diagnosis and management. We evaluated the clinical practices among healthcare professionals concerning jaundiced newborns and their ability to recognize pale stools. We supplied a questionnaire and a panel with eight photographs of stools, both locally validated, to physicians and nurses of the National Healthcare Service. Analysis was conducted according to professional status, specialization and years of experience of professionals and level of healthcare. Questionnaires were administered to 266 participants (100 physicians, 166 nurses). The decision to send patients to medical observation depended on the intensity of jaundice for a significant percentage of nurses. Concerning jaundiced newborns breastfed and otherwise healthy, 28.9% of physicians would never request a conjugated bilirubin assay, and only 43.3% would request it after 14 days old; for those with other signs/symptoms of disease, only 69.1% of physicians would request it immediately. Multiple linear regression analysis identified specialization as an independent variable significantly associated with the ability to recognize pale stools. CONCLUSION A significant percentage of healthcare professionals assumed clinical practices that preclude the timely recognition of cholestasis/pale stools, reinforcing the idea of educational needs. Specialization, rather than years of experience of professionals, was associated with better skills and practices. What is Known: • Neonatal cholestasis is a condition with some rare underlying entities having high mortality and morbidity. Early diagnosis is crucial to improve prognosis. Yet, many cases remain late recognized and referred. • Studies evaluating the ability of healthcare professionals to recognize neonatal cholestasis are scarce. What is New: • In this study, a significant percentage of professionals assumed clinical practices that preclude timely recognition of neonatal cholestasis and pale stools, reinforcing the idea of educational needs. • Specialization of professionals was associated with better skills and practices.
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Affiliation(s)
- Ermelinda Santos Silva
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge Viterbo Ferreira, nº 228, 4050-313, Porto, Portugal. .,Gastroenterology Unit, Paediatrics Division, Departmento da Criança e do Adolescente, Centro Materno-Infantil do Norte, Centro Hospitalar do Porto, Largo da Maternidade Júlio Dinis, 4050-651, Porto, Portugal.
| | - Helena Moreira Silva
- Paediatrics Division, Departamento da Criança e do Adolescente, Centro Materno-Infantil do Norte, Centro Hospitalar do Porto, Largo da Maternidade Júlio Dinis, 4050-651, Porto, Portugal
| | - Lia Azevedo Lijnzaat
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge Viterbo Ferreira, nº 228, 4050-313, Porto, Portugal
| | - Cláudia Melo
- Paediatrics Division, Unidade Hospitalar de Famalicão, Centro Hospitalar do Médio Ave, Rua de Cupertino de Miranda, 4764-958, Vila Nova de Famalicão, Portugal
| | - Elísio Costa
- UCIBIO, Department of Biological Sciences, Faculdade de Farmácia, Universidade do Porto, Rua Jorge Viterbo Ferreira, nº 228, 4050-313, Porto, Portugal
| | - Esmeralda Martins
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge Viterbo Ferreira, nº 228, 4050-313, Porto, Portugal.,Metabolic Diseases Unit, Paediatrics Division, Departmento da Criança e do Adolescente, Centro Materno-Infantil do Norte, Centro Hospitalar do Porto, Largo da Maternidade Júlio Dinis, 4050-651, Porto, Portugal
| | - Ana Isabel Lopes
- Gastroenterology Unit, Paediatrics Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Av. Prof. Egas Moniz, 1600-190, Lisboa, Portugal.,Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal
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Abstract
The pathway from clinical suspicion to establishing the diagnosis of biliary atresia in a child with jaundice is a daunting task. However, investigations available help to point towards the correct diagnosis in reasonable time frame. Imaging by Sonography has identified several parameters which can be of utility in the diagnostic work up. Comparison of Sonography with imaging by Nuclear medicine can bring out the significant differences and also help in appropriate imaging. The battery of Biochemical tests, available currently, enable better understanding of the line-up of investigations in a given child with neonatal cholestasis. Management protocols enable standardized care with optimal outcome. The place of surgical management in biliary atresia is undisputed, although Kasai procedure and primary liver transplantation have been pitted against each other. This article functions as a platform to bring forth the various dimensions of biliary atresia.
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da Silva FV, Ferri PM, Nascentes Queiroz TC, de Souza Haueisen Barbosa P, Cassiano de Oliveira MC, de Melo Pereira LJ, Simões E Silva AC, Penna FJ, Druve Tavares Fagundes E, Ferreira AR. Nutritional evaluation of children with chronic cholestatic disease. J Pediatr (Rio J) 2016; 92:197-205. [PMID: 26632247 DOI: 10.1016/j.jped.2015.07.006] [Citation(s) in RCA: 10] [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: 04/06/2015] [Revised: 06/30/2015] [Accepted: 07/13/2015] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate the nutritional status of children with persistent cholestasis and to compare the anthropometric indices between children with and without liver cirrhosis and children with and without jaundice. METHODS Children with persistent cholestasis, i.e. increased direct bilirrubin or changes in the canalicular enzyme gamma-glutamyl transferase (GGT), were included. The anthropometric measures were weight (W), height or length (H), arm circumference (AC), triceps skinfold thickness (TST), arm muscle circumference (AMC), and body mass index (BMI). RESULTS Ninety-one children with cholestasis, with current median age of 12 months, were evaluated. W/age (A) and H/A indices below -2 Z-scores were observed in 33% and 30.8% of patients, respectively. Concerning the W/H index and BMI, only 12% and 16% of patients, respectively, were below -2 Z-scores. Regarding AC, 43.8% of 89 evaluated patients had some depletion. Observing the TST, 64% of patients had depletion, and 71.1% of the 45 evaluated patients had some degree of depletion regarding the ACM index. CONCLUSION Evaluation using weight in patients with chronic liver diseases may overestimate the nutritional status due to visceromegaly, subclinical edema, or ascites. Indices that correlate weight and height, such as W/H and BMI, may also not show depletion because of the chronic condition in which there are depletion of both weight and height. TST, AC, and ACM are parameters that better estimate nutritional status and should be part of the management of patients with liver diseases and cholestasis.
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Affiliation(s)
- Francislaine Veiga da Silva
- Group of Pediatric Hepatology and Gastroenterology, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Pediatric Gastroenterology Group, School of Medicine, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Priscila Menezes Ferri
- Pediatric Gastroenterology Group, School of Medicine, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Department of Pediatrics, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.
| | - Thaís Costa Nascentes Queiroz
- Pediatric Gastroenterology Group, School of Medicine, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Medical Pediatric Gastroenterologist, Brazil
| | | | | | | | - Ana Cristina Simões E Silva
- Department of Pediatrics, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Interdisciplinary Laboratory of Medical Investigation, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Francisco José Penna
- Pediatric Gastroenterology Group, School of Medicine, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Department of Pediatrics, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Eleonora Druve Tavares Fagundes
- Pediatric Gastroenterology Group, School of Medicine, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Department of Pediatrics, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Alexandre Rodrigues Ferreira
- Pediatric Gastroenterology Group, School of Medicine, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Department of Pediatrics, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.
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47
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Arafa RS, Abdel Haie OM, El-Azab DS, Abdel-Rahman AM, Sira MM. Significant hepatic expression of IL-2 and IL-8 in biliary atresia compared with other neonatal cholestatic disorders. Cytokine 2016; 79:59-65. [PMID: 26765485 DOI: 10.1016/j.cyto.2015.12.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 12/14/2015] [Accepted: 12/29/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Although the exact etiology of biliary atresia (BA) is still elusive, inflammation plays a key role. Release of proinflammatory cytokines from activated immune cells perpetuates the injury and causes biliary destruction. We aimed to study interleukin (IL)-2 and IL-8 expression in liver tissue of BA patients compared with other neonatal cholestatic disorders. METHODS The study included 59 infants with neonatal cholestasis in two groups; BA group (n=31) and non-BA group (n=28) with cholestatic disorders other than BA as controls. Demographic, clinical, laboratory, and histopathological parameters were collected. IL-2 and IL-8 immunostaining was performed. Immunostaining in portal cellular infiltrate was scored as positive or negative and expressed as the mean cell count in three portal tracts. RESULTS The mean value of IL-2 and IL-8 positive inflammatory cells was significantly higher in BA than in non-BA group (P-values of 0.004 and 0.002 respectively). IL-2 correlated significantly with IL-8 immunostaining in both BA and non-BA group (P<0.0001 for both). Furthermore, both cytokines in both groups correlated significantly with inflammatory activity in liver biopsy while there was no significant correlation with the other studied parameters. Yet, there was a trend of increased expression of IL-2 and IL-8 with increasing stage of fibrosis in BA group. This trend was not observed in non-BA group. CONCLUSION The significantly higher expression of IL-2 and IL-8 in patients with BA compared to non-BA suggests a potential role for these cytokines in the pathogenesis in therapy of this devastating neonatal hepatic disorder.
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Affiliation(s)
- Reda Sanad Arafa
- Department of Pediatrics, Faculty of Medicine, Benha University, Egypt
| | | | - Dina Shehata El-Azab
- Department of Pathology, National Liver Institute, Menofiya University, 32511 Shebin El-koom, Menofiya, Egypt
| | | | - Mostafa M Sira
- Department of Pediatric Hepatology, National Liver Institute, Menofiya University, 32511 Shebin El-koom, Menofiya, Egypt.
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Yamaguchi H, Kosugiyama K, Honda S, Tadao O, Taketomi A, Iwata S. Down Syndrome with Patent Ductus Venosus and Hepato-Biliary-Pancreatic Abnormalities. Indian J Pediatr 2016; 83:78-80. [PMID: 26096864 DOI: 10.1007/s12098-015-1797-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 05/18/2015] [Indexed: 11/27/2022]
Abstract
The association between Down syndrome and congenital portosystemic shunts, most commonly caused by patent ductus venosus, remains relatively unknown. The authors present a girl with Down syndrome with patent ductus venosus, pancreaticobiliary maljunction and paucity of interlobular bile ducts, presenting with neonatal cholestasis and transient abnormal myeloproliferative disorder. To the best of authors' knowledge, no report of the concurrent presence of the above in Down syndrome has been published.
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Affiliation(s)
- Hiroshi Yamaguchi
- Department of Pediatrics, Teine Keijinkai Hospital, 1 Jo 12-1-40, Maeda, Teine-ku, Sapporo, Japan.
| | - Kiyotaka Kosugiyama
- Department of Pediatrics, Teine Keijinkai Hospital, 1 Jo 12-1-40, Maeda, Teine-ku, Sapporo, Japan
| | - Shohei Honda
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, Japan
| | - Okada Tadao
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, Japan
| | - Seido Iwata
- Department of Pediatrics, Teine Keijinkai Hospital, 1 Jo 12-1-40, Maeda, Teine-ku, Sapporo, Japan
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49
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Faverey LC, Vandenplas Y. Hemorrhagic diathesis as the presenting symptom of neonatal cholestasis. Pediatr Gastroenterol Hepatol Nutr 2014; 17:191-5. [PMID: 25349836 PMCID: PMC4209325 DOI: 10.5223/pghn.2014.17.3.191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 08/13/2014] [Accepted: 08/23/2014] [Indexed: 11/14/2022] Open
Abstract
A 4-week-old infant presented with a coagulation disorder resulting from a vitamin K deficiency. The vitamin K deficiency was caused by neonatal cholestasis due to biliary atresia. Jaundice, hepatomegaly and pale stools are the predominant presenting symptoms of biliary atresia, none of which were recognized in our patient before admission. However, the patient presented with bleeding caused by vitamin K deficiency. She was fully breastfed and had received adequate doses of vitamin K at birth and from the age of 1 week. In case of a hemorrhagic diathesis due to neonatal cholestasis, timely identification of treatable underlying disorders, in particular biliary atresia, is important because an early surgical intervention results in a better prognosis. Meticulous history taking and a thorough physical exam can be decisive for an early diagnosis and subsequent intervention.
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Affiliation(s)
| | - Yvan Vandenplas
- Department of Pediatrics, Universitair Ziekenhuis Brussel, Brussels, Belgium
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50
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El-Guindi MAS, Sira MM, Sira AM, Salem TAH, El-Abd OL, Konsowa HAS, El-Azab DS, Allam AAH. Design and validation of a diagnostic score for biliary atresia. J Hepatol 2014; 61:116-23. [PMID: 24657403 DOI: 10.1016/j.jhep.2014.03.016] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 02/22/2014] [Accepted: 03/10/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The dilemma of early diagnosis of biliary Atresia (BA), particularly distinguishing it from other causes of neonatal cholestasis is challenging. The aim was to design and validate a scoring system for early discrimination of BA from other causes of neonatal cholestasis. METHODS A twelve-point scoring system was proposed according to clinical, laboratory, ultrasonographic, and histopathological parameters. A total of 135 patients with neonatal cholestasis in two sets were recruited to design (n=60) and validate (n=75) a scoring system. Parameters with significant statistical difference between BA (n=30) and non-BA (n=30) patients in the design set were analyzed by logistic regression to predict the presence or absence of BA then a scoring system was designed and validated. RESULTS The total score ranged from 0 to 37.18 and a cut-off value of >23.927 could discriminate BA from other causes of neonatal cholestasis with sensitivity and specificity of 100% each. By applying this score in the validation set, the accuracy was 98.83% in predicting BA. The diagnosis of BA was proposed correctly in 100% and the diagnosis of non-BA was proposed correctly in 97.67% of patients. By applying this model, unnecessary intraoperative cholangiography would be avoided in non-BA patients. CONCLUSIONS This scoring system accurately separates infants with BA and those with non-BA, rendering intraoperative cholangiography for confirming or excluding BA unnecessary in a substantial proportion of patients.
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Affiliation(s)
- Mohamed Abdel-Salam El-Guindi
- Department of Pediatric Hepatology, National Liver Institute, Menofiya University, 32511 Shebin El-koom, Menofiya, Egypt
| | - Mostafa Mohamed Sira
- Department of Pediatric Hepatology, National Liver Institute, Menofiya University, 32511 Shebin El-koom, Menofiya, Egypt.
| | - Ahmad Mohamed Sira
- Department of Pediatric Hepatology, National Liver Institute, Menofiya University, 32511 Shebin El-koom, Menofiya, Egypt
| | - Tahany Abdel-Hameed Salem
- Department of Pediatric Hepatology, National Liver Institute, Menofiya University, 32511 Shebin El-koom, Menofiya, Egypt
| | - Osama Lotfy El-Abd
- Department of Radiology, National Liver Institute, Menofiya University, 32511 Shebin El-koom, Menofiya, Egypt
| | - Hatem Abdel-Sattar Konsowa
- Department of Pediatric Hepatology, National Liver Institute, Menofiya University, 32511 Shebin El-koom, Menofiya, Egypt
| | - Dina Shehata El-Azab
- Department of Pathology, National Liver Institute, Menofiya University, 32511 Shebin El-koom, Menofiya, Egypt
| | - Alif Abdel-Hakim Allam
- Department of Pediatric Hepatology, National Liver Institute, Menofiya University, 32511 Shebin El-koom, Menofiya, Egypt
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