Progressive familial intrahepatic cholestasis

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Progressive familial intrahepatic cholestasis
Other namesPFIC [1]
Specialty Internal medicine

Progressive familial intrahepatic cholestasis (PFIC) is a group of familial cholestatic conditions caused by defects in biliary epithelial transporters. The clinical presentation usually occurs first in childhood with progressive cholestasis. This usually leads to failure to thrive, cirrhosis, and the need for liver transplantation.[ citation needed ]

Contents

Types

Types of progressive familial intrahepatic cholestasis are as follows:[ citation needed ]

Signs and symptoms

The onset of the disease is usually before age 2, but patients have been diagnosed with PFIC even into adolescence. Of the three entities, PFIC-1 usually presents earliest. Patients usually present in early childhood with cholestasis, jaundice, and failure to thrive. Intense pruritus is characteristic; [2] in patients who present in adolescence, it has been linked with suicide. Patients may have fat malabsorption, leading to fat soluble vitamin deficiency, and complications, including osteopenia. [3]

Pathogenesis

Progressive familial intrahepatic cholestasis is inherited in an autosomal recessive pattern. Autorecessive.svg
Progressive familial intrahepatic cholestasis is inherited in an autosomal recessive pattern.

PFIC-1 is caused by a variety of mutations in ATP8B1 , a gene coding for a P-type ATPase protein, FIC-1, that is responsible for phospholipid translocation across membranes. [4] It was previously identified as clinical entities known as Byler's disease and Greenland-Eskimo familial cholestasis. Patients with PFIC-1 may also have watery diarrhea, in addition to the clinical features below, due to FIC-1's expression in the intestine. How ATP8B1 mutation leads to cholestasis is not yet well understood.[ citation needed ]

PFIC-2 is caused by a variety of mutations in ABCB11 , the gene that codes for the bile salt export pump, or BSEP. Retention of bile salts within hepatocytes, which are the only cell type to express BSEP, causes hepatocellular damage and cholestasis.[ citation needed ]

PFIC-3 is caused by a variety of mutations in ABCB4 , the gene encoding multidrug resistance protein 3 (MDR3), [5] which codes for a floppase responsible for phosphatidylcholine translocation. The defective phosphatidylcholine translocation leads to a lack of phosphatidylcholine in bile. Phosphatidylcholine normally chaperones bile acids, preventing damage to the biliary epithelium. The free or "unchaperoned" bile acids in bile of patients with MDR3 deficiency cause a cholangitis. Biochemically, this is of note, as PFIC-3 is associated with a markedly elevated GGT.[ citation needed ]

The inheritance pattern of all three forms of PFIC defined to date is autosomal recessive.[ citation needed ]

Liver biopsies typically show evidence of cholestasis (including bile plugs and bile infarcts), duct hypoplasia, hepatocellular injury, and Zone 3 fibrosis. Giant cell change and other features of hepatocellular injury are more pronounced in PFIC-2 than in PFIC-1 or PFIC-3. End-stage disease in all forms of PFIC defined to date is characterized by bridging fibrosis with duct proliferation in peri-portal regions. [6]

Diagnosis

Biochemical markers include a normal GGT for PFIC-1 and -2, with a markedly elevated GGT for PFIC-3. Serum bile acid levels are grossly elevated. Serum cholesterol levels are typically not elevated, as is seen usually in cholestasis, as the pathology is due to a transporter as opposed to an anatomical problem with biliary cells.[ citation needed ]

Treatment

Initial treatment is supportive, with the use of agents to treat cholestasis and pruritus, including the following:[ citation needed ]

The partial external biliary diversion (PEBD) procedure is a surgical approach that diverts bile from the gallbladder externally into an ileostomy bag. [7]

Patients should be supplemented with fat-soluble vitamins, and occasionally medium-chain triglycerides in order to improve growth. When liver synthetic dysfunction is significant, patients should be listed for transplantation. Family members should be tested for PFIC mutations, in order to determine risk of transmission.[ citation needed ]

Prognosis

The disease is typically progressive, leading to fulminant liver failure and death in childhood, in the absence of liver transplantation. Hepatocellular carcinoma may develop in PFIC-2 at a very early age; even toddlers have been affected.[ citation needed ]

Epidemiology

See also

Related Research Articles

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<span class="mw-page-title-main">Caroli disease</span> Medical condition

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<span class="mw-page-title-main">Biliary atresia</span> Medical condition

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<span class="mw-page-title-main">Primary biliary cholangitis</span> Autoimmune disease of the liver

Primary biliary cholangitis (PBC), previously known as primary biliary cirrhosis, is an autoimmune disease of the liver. It results from a slow, progressive destruction of the small bile ducts of the liver, causing bile and other toxins to build up in the liver, a condition called cholestasis. Further slow damage to the liver tissue can lead to scarring, fibrosis, and eventually cirrhosis.

<span class="mw-page-title-main">Hep G2</span>

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<span class="mw-page-title-main">Primary sclerosing cholangitis</span> Medical condition

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<span class="mw-page-title-main">Aagenaes syndrome</span> Medical condition

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<span class="mw-page-title-main">Alagille syndrome</span> Medical condition

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<span class="mw-page-title-main">Citrullinemia</span> Medical condition

Citrullinemia is an autosomal recessive urea cycle disorder that causes ammonia and other toxic substances to accumulate in the blood.

<span class="mw-page-title-main">Cholestasis</span> Medical condition

Cholestasis is a condition where bile cannot flow from the liver to the duodenum. The two basic distinctions are an obstructive type of cholestasis where there is a mechanical blockage in the duct system that can occur from a gallstone or malignancy, and metabolic types of cholestasis which are disturbances in bile formation that can occur because of genetic defects or acquired as a side effect of many medications. Classification is further divided into acute or chronic and extrahepatic or intrahepatic.

<span class="mw-page-title-main">Rotor syndrome</span> Medical condition

Rotor syndrome is a rare cause of mixed direct (conjugated) and indirect (unconjugated) hyperbilirubinemia, relatively benign, autosomal recessive bilirubin disorder characterized by non-hemolytic jaundice due to the chronic elevation of predominantly conjugated bilirubin.

Neonatal cholestasis refers to elevated levels of conjugated bilirubin identified in newborn infants within the first few months of life. Conjugated hyperbilirubinemia is clinically defined as >20% of total serum bilirubin or conjugated bilirubin concentration greater than 1.0 mg/dL regardless of total serum bilirubin concentration. The differential diagnosis for neonatal cholestasis can vary extensively. However, the underlying disease pathology is caused by improper transport and/or defects in excretion of bile from hepatocytes leading to an accumulation of conjugated bilirubin in the body. Generally, symptoms associated with neonatal cholestasis can vary based on the underlying cause of the disease. However, most infants affected will present with jaundice, scleral icterus, failure to thrive, acholic or pale stools, and dark urine.

<span class="mw-page-title-main">Intrahepatic cholestasis of pregnancy</span> Medical condition

Intrahepatic cholestasis of pregnancy (ICP), also known as obstetric cholestasis, cholestasis of pregnancy, jaundice of pregnancy, and prurigo gravidarum, is a medical condition in which cholestasis occurs during pregnancy. It typically presents with itching and can lead to complications for both mother and fetus.

<span class="mw-page-title-main">Liver cancer</span> Medical condition

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<span class="mw-page-title-main">ABCB11</span> Protein-coding gene in the species Homo sapiens

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<span class="mw-page-title-main">ABCB4</span> Protein-coding gene in the species Homo sapiens

The ATP-binding cassette 4 (ABCB4) gene encodes multidrug resistance protein 3. ABCB4 is associated with progressive familial intrahepatic cholestasis type 3 and intrahepatic cholestasis of pregnancy.

<span class="mw-page-title-main">Phospholipid-transporting ATPase IC</span> Protein-coding gene in the species Homo sapiens

Probable phospholipid-transporting ATPase IC is an enzyme that in humans is encoded by the ATP8B1 gene. This protein is associated with progressive familial intrahepatic cholestasis type 1 as well as benign recurrent intrahepatic cholestasis.

MDR3 may refer to:

<span class="mw-page-title-main">Odevixibat</span> Medication

Odevixibat, sold under the brand name Bylvay, is a medication for the treatment of progressive familial intrahepatic cholestasis. It is taken by mouth. Odevixibat is a reversible, potent, selective inhibitor of the ileal bile acid transporter (IBAT). It was developed by Albireo Pharma.

References

  1. RESERVED, INSERM US14-- ALL RIGHTS. "Orphanet: Progressive familial intrahepatic cholestasis". www.orpha.net. Retrieved 29 September 2019.
  2. Shneider BL (2004). "Progressive intrahepatic cholestasis: mechanisms, diagnosis and therapy". Pediatric Transplantation. 8 (6): 609–12. doi:10.1111/j.1399-3046.2004.00240.x. PMID   15598335.
  3. "eMedicine - Progressive Familial Intrahepatic Cholestasis : Article by Karan M Emerick, MD" . Retrieved 2007-07-21.
  4. Bull LN, van Eijk MJ, Pawlikowska L, et al. (1998). "A gene encoding a P-type ATPase mutated in two forms of hereditary cholestasis". Nat. Genet. 18 (3): 219–24. doi:10.1038/ng0398-219. PMID   9500542. S2CID   9897047.
  5. Jacquemin E, De Vree JM, Cresteil D, et al. (2001). "The wide spectrum of multidrug resistance 3 deficiency: from neonatal cholestasis to cirrhosis of adulthood". Gastroenterology. 120 (6): 1448–58. doi:10.1053/gast.2001.23984. PMID   11313315.
  6. Alonso EM, Snover DC, Montag A, Freese DK, Whitington PF (1994). "Histologic pathology of the liver in progressive familial intrahepatic cholestasis". J. Pediatr. Gastroenterol. Nutr. 18 (2): 128–33. doi: 10.1097/00005176-199402000-00002 . PMID   8014759.
  7. "Surgical Treatment of PFIC". www.pfic.org. Archived from the original on 17 June 2016. Retrieved 14 March 2022.