Deciphering the causes of
neonatal cholestasis
Jorge A. Bezerra, M.D.
Division of Pediatric GI,
Hepatology, & Nutrition
Clinical Problem - 1
Full term infant; no complications
Jaundice at day 2; resolution by day 9
At 2 months of age
Breastfeeding
Well-infant visit:
Good weight gain; jaundice; decreased appetite
AST: 124 IU/L
AST: 157 IU/L
Albumin: 3.5 g/dL
Conjugated bilirubin: 3.8 mg/dL
APh: 420 GTP: 587 IU/L
What is the diagnosis?
Clinical Problem - 2
3.5 yr old boy with jaundice and pruritus
Ht/Wt ~50th%ile
AST: 167 IU/L
AST: 142 IU/
Albumin: 3.6 g/dL
Conjugated bilirubin: 2.6 mg/dL
Serum bile acids: 56; GTP: 22 IU/L
No hepatomegaly; spleen 3 cm LCM
Jaundice in the first 2 months of age
No history of diarrhea
What is the diagnosis?
Clinical Problem - 3
6 month old boy with:
Arthrogryposis multiplex congenita
Jaundice
Conjugated bili: 4.3 mg/dL; GTP: 32 IU/L
Normal synthetic function
Renal dysfunction
Renal Fanconi syndrome
Nephrocalcinosis
Liver histology
Giant cell transformation; ductopenia
What is the diagnosis?
Mutation in the VPS33B gene
Cholestasis as a sign/symptom
Neonatal
cholestasis
Childhood
cholestasis
Non-hepatic
syndrome
Cholestasis
Cholestasis
Pigment of my imagination?
PHYSIOLOGIC
Abnormal decrease in biliary flow
HISTOPATHOLOGIC
Histological evidence of bile within
canaliculi or bile ducts
CLINICAL
Accumulation of substances normally
excreted by bile in plasma and extrahepatic
systems
The hepatic excretory system
Bile
Unconj. Bili
Aminoacids
Organic anions
Others
Conj. bilirubin
Bile acids
Lipids (cholesterol)
Proteins
Lytes, Vitamins...
Cholestasis and sites of injury
Bile
Unconj. Bili
Aminoacids
Organic anions
Others
Conj. bilirubin
Bile acids
Lipids (cholesterol)
Proteins
Lytes, Vitamins...
Intrahepatic cholestasis
12 months
JAUNDICE
COAGULOPATHY
XANTHOMA (?)
RICKETTS (?)
>12 months
JAUNDICE
COAGULOPATHY
XANTHOMA
RICKETTS
NEURO DEFICITS
PRURITUS
Temporal dynamics of jaundice
3 wk of age, breastfed
growing well (5-10th%ile), jaundiced
Bilirubin
U.B.
U.B.
2 wk
C.B.
4 wk
Evolving spectrum of cholestasis
<1970
-INFECTION
-IDIOPATHIC
-ATRESIA
1970-2000
-INFECTION
-ATRESIA
-A1AT def (met)
-ALAGILLE
-PFIC
-IDIOPATHIC
Clinical Problem - 1
Full term infant; no complications
Jaundice at day 2; resolution by day 9
At 2 months of age
Breastfeeding
Well-infant visit:
Good weight gain; jaundice; decreased appetite
AST: 124 IU/L
AST: 157 IU/L
Albumin: 3.5 g/dL
Conjugated bilirubin: 3.8 mg/dL
APh: 420 GTP: 587 IU/L
What is the diagnosis? A1AT PiZZ
A1AT Deficiency
Infant with cholestasis
11 month old male infant
History of transient neonatal jaundice
Exam
Typical facial features, posterior embryotoxon
Cardiac murmur, vertebral body abnormalities
Laboratory studies:
AST: 111 IU/L
AST: 108 IU/L
Albumin: 3.7 g/dL
Conjugated bilirubin: 2.9 mg/dL
APh: 201 GTP: 387 IU/L
Cholesterol: 785
The Alagille Disease
The Alagille Disease
SIGNAL PEPTIDE
EGF-like
repeats
CYSTEINE
TRANSMEMBRANE
INTRACELLULAR
DOMAIN
JAG1 protein
The Alagille Disease
Main Criteria
Interlobular bile ducts
Extrahepatic involvement:
Facial features
Vertebral body abnormalities
Cardiovascular defects
Posterior embryotoxon
Renal abnormalities
91%
95%
87%
70%
89%
68%
The Alagille Disease
Minor Criteria
Poor growth
Inadequate development
Hypogonadism
Bone disease
High-pitched voice
Abnormal vasculature in
central nervous system
50%
60%
<10%
<10%
<10%
?
The hepatic excretory system
Bile
JAG1
Evolving spectrum of cholestasis
<1970
-INFECTION
-IDIOPATHIC
-ATRESIA
1970-2000
-INFECTION
-ATRESIA
-METABOLIC
-ALAGILLE
-PFIC
-IDIOPATHIC
2000...
-INFECTION
-ATRESIA
-METABOLIC
-ALAGILLE
-FIC1 DEFECT (PFIC1)
-FIC1 DEFECT (GREENLAND)
-FIC1 DEFECT (BRIC)
-FIC1 DEFECT (FAROE IS.)
-BSEP DEFICIENCY (PFIC2)
-MDR3 DEFICIENCY (PFIC3)
-3HSD DEFICIENCY
-IDIOPATHIC (VARIANTS ?)
ABC Transporters
A lesson in family values
FIC1
MDR3
BSEP
MRP2
United to promote biliary flow
PFIC syndromes
MRP2 (Conj. bili)
FIC1 (P-ilserine)
Bile
Mutant 3HSD
BSEP (Bile salts)
MDR3 (phospholipids)
FIC1?
PFIC syndromes
Familial cholestasis
Progression to end-stage liver disease
Clinical features
Cholestasis: recurrent or persistent
Autosomal recessive pattern
Variable levels of aminotransferases
Subgroup with low levels of GTP
Typical histologic/EM findings
Exclusion of known causes of chronic
cholestasis
Neonatal cholestasis
NEONATAL
CHOLESTASIS
Use of LFTs in
to identify PFIC
INFECTION
BILIARY ATRESIA
METABOLIC DISEASE
IDIOPATHIC
GTP
AST/ALT: Elevated
Conjugated bili: Elevated
GTP: ()
Alk Phosph: Elevated
Elevated bile acids ()
Elevated cholesterol ()
FIC1 defect
Bylers disease
Onset of cholestasis in the 1st yr of life
Recurrent cholestasis
cirrhosis
Pruritus
Diarrhea, pancreatitis, hearing defect
Gamma-GTP: Normal or low
Histology
Canalicular cholestasis, mild ductular
changes or inflammation, granular bile (ME)
Often require OLT before 10 years
Molecular defect
Translocation of Ph-tidylserine and Phethanolamine from inner to outer leaflet
EM: Granular bile
FIC1 defect
BRIC & Cholestasis in Faraoe Is.
Recurrent cholestasis
No progression to cirrhosis
Cycles: Jaundice, pruritus, weight
loss, steatorrhea
Gamma-GTP: Normal or low
Histology: Normal or minimal changes
Require treatment for pruritus
FIC1 defect
Greenland familial cholestasis
Progressive cholestasis
Pruritus, steatorrhea, poor growth
Gamma-GTP: Normal or low
Histology:
Fibrosis, granular bile (ME)
Mortality: 50% at 3 years
BSEP deficiency
Clinical features similar to Bylers
Recurrent cholestasis, pruritus
Progression to chronic liver disease
Gamma-GTP: Normal or low
Lack of extrahepatic manifestations
Genetic mutations in 2q24
Histology
Giant cell hepatitis, inflammation, progression
to fibrosis, canalicular cholestasis
Molecular defect
Export of bile salt into canalicular
BSEP deficiency
BRIC-2
van Mill et al. Gastroenterology
2004;127:379
Clinical features similar to BRIC
Recurrent cholestasis, pruritus
No evidence of disease progression
Gamma-GTP: Normal or low
Histology
No evidence of severe fibrosis
Sequence of BSEP (ABCB11) gene
Mutation
Spectrum of disease of BSEP deficiency
MDR3 deficiency
Clinical features similar to Bylers
Milder symptoms
Progression to chronic liver disease: slow?
High GTP
Histology
Portal inflammation, ductal proliferation
Variable degree of fibrosis
Other diseases
Intrahepatic cholestasis of pregnancy
Cholesterol-rich cholelithiasis
Molecular defect
Impaired export of aminophospholipids
3HSD deficiency
Clinical features similar to Bylers
Deficiency of fat-soluble vitamins
Gamma-GTP: Normal or low
High conjugated bilirubin
Bile acids: Normal/low (cholestasis)
Absence of pruritus
Histology
Portal inflammation, variable fibrosis
Coagulopathy and vitamin deficiency
improve with UDCA
The hepatic transport system
A1AT deficiency
MRP2
Dubin-Johnson
FIC1 defect
BSEP deficiency
MDR3 deficiency
FIC1 defect
FIC1
BSEP
MDR3
Mutant
3HSD
FIC1?
JAG1
Cystic fibrosis
BASD
Cl-
CFTR
Alagille synd.
Evolving spectrum of cholestasis
1970-2000
2000...
2005
Intrahepatic cholestasis
Clinical syndromes
Complex group; different prognosis
Incidence
Individually: rare; as a group: frequent
Challenge: group patients
Clinical features
Syndromic features? Pruritus? Severity?
Biochemical markers
PT/INR; conj (direct) bili; GTP
Liver biopsy
Molecular diagnosis: not routine
Intrahepatic cholestasis
Treatment
Nutritional support
Calories to promote adequate growth
A,D,E,K vitamin supplementation
UDCA: 15-30 mg/kg/day
Pruritus
Add rifampin: increases bile acid excretion
Biliary diversion
External biliary diversion
Internal biliary diversion
May halt progression of liver disease
Liver transplantation
Relationship between cholestasis
and multi-system disease
1970-2000
-INFECTION
-ATRESIA
-A1AT def (met)
-ALAGILLE
-PFIC
-IDIOPATHIC
2000...
-INFECTION
-ATRESIA
-A1AT def (met)
-ALAGILLE
-FIC1 DEFECT (PFIC1)
-FIC1 DEFECT (GREENLAND)
-FIC1 DEFECT (BRIC)
-FIC1 DEFECT (FAROE IS.)
-BSEP DEFICIENCY (PFIC2)
-MDR3 DEFICIENCY (PFIC3)
-3HSD DEFICIENCY
-IDIOPATHIC (VARIANTS ?)
2005
-INFECTION
-ATRESIA
-A1AT def, CF
-ALAGILLE
-FIC1 defect
-BSEP deficiency
-MDR3 deficiency
-3HSD deficiency
-Unclassified
-Cholestasis and
multi-system Dz
Summation
Present as jaundice, pruritus, and/or
complications of deficiency of ADEK
Neonatal onset; pre- or school age
Biochemistry: bilirubin vs GTP
Liver biopsy: cellular organization,
degree of fibrosis, EM
Nutritional support, ADEK
Treatment of pruritus
Medication
Surgery
Liver transplantation
Unclassified syndromes
Lymphedema-cholestasis syndrome or
Aaganaes syndrome
Lymphedema: mostly lower extremities
Episodic intrahepatic cholestasis
Low GTP
Cholesterol levels may be low
Variable progression of liver disease
Autosomal recessive
Two loci may exist (LCS-1 and LCS-2)
Unclassified syndromes
North-American Indian childhood cirrhosis
(NAIC syndrome)
Severe form of intrahepatic cholestasis
Typically presents with mild neonatal
cholestasis, but progresses to biliary cirrhosis
Liver transplantation: only effective treatment
Mutation in Cirhin (CIRH1A)
Mostly expressed in the embryonic liver
The biological relationship between Cirhin and
cholestasis is unknown
Unclassified syndromes
Neonatal intrahepatic cholestasis caused
by citrin deficiency (NICCD syndrome)
Type II cytrulinemia (adult-onset)
Neonatal cholestasis; micro/macro steatosis
Variable degrees of synthetic dysfunction
Vomiting, poor growth, irritability
Mutation in citrin (SLC25A13), 7q21.3 mitochondrial aspartate-glutamate carrier
Markedly elevated plasma citrullin, high
methionine, hypergalactosemia
Supportive care; improvement by 1 yr of age
Relationship between cholestasis
and multi-system disease
Arthrogryposis-renal dysfunctioncholestasis syndrome (ARC syndrome)
Neurogenic arthrogryposis multiplex
congenita
Renal tubular dysfunction: nephrocalcinosis,
renal Falconi syndrome
Neonatal cholestasis, low GTP, duct paucity
Death in the first year of life
Mutation in the VPS33B gene (15q26.1)
Abnormal protein trafficking & memb. fusion
Relationship between cholestasis
and multi-system disease
McCune-Albright syndrome
Polyostotic fibrous dysplasia, caf-au-lait skin
pigmentation
Peripheral precocious puberty in girls
Cholestasis: basis of cholestasis is unknown
Postzygotic activating mutations of arginine 201 in
the G protein-alpha subunit
Niemann-Pick syndrome disease type C
Neonatal cholestasis, disproportionate splenomegaly
Mild developmental delay
Defective cellular cholesterol esterification
The hepatic transport system
K+
MRP2 (Conj. bili)
Na+
NTCP
FIC1 (P-ilserine)
Bile
OATPs
BSEP (Bile salts)
MDR3 (phospholipids)
hOCT1
FIC1?
IBAT
CFTR
AE2
ClClHCO3-
The hepatic transport system
AT-ZZ
MRP2 (Conj. bili)
FIC1 (P-ilserine)
Bile
Mutant 3HSD
BSEP (Bile salts)
MDR3 (phospholipids)
FIC1?
JAG1
