Delta 4-3-oxosteroid 5 beta-reductase deficiency described in identical twins with neonatal hepatitis. A new inborn error in bile acid synthesis.

A new inborn error in bile acid synthesis, manifest in identical infant twins as severe intrahepatic cholestasis, is described involving the delta 4-3-oxosteroid 5 beta-reductase catalyzed conversion of the key intermediates, 7 alpha-hydroxy-4-cholesten-3-one and 7 alpha,12 alpha-dihydroxy-4-cholesten-3-one for chenodeoxycholic and cholic acid synthesis, to the respective 3 alpha-hydroxy-5 beta (H) products. This defect was detected by fast atom bombardment ionization-mass spectrometry from an elevated excretion and predominance of taurine conjugated unsaturated hydroxy-oxo-bile acids. Gas chromatography-mass spectrometry confirmed these to be 7 alpha-hydroxy-3-oxo-4-cholenoic and 7 alpha,12 alpha-dihydroxy-3-oxo-4-cholenoic acids (75-92% of total). Fasting serum bile acid concentrations were greater than 37 mumol/liter; chenodeoxycholic acid was the major bile acid, but significant amounts of allo(5 alpha-H)-bile acids (approximately 30%) were present. Biliary bile acid concentration was less than 2 mumol/liter and consisted of chenodeoxycholic, allo-chenodeoxycholic, and allo-cholic acids. These biochemical findings, which were identical in both infants, indicate a defect in bile acid synthesis involving the conversion of the delta 4-3-oxo-C27 intermediates into the corresponding 3 alpha-hydroxy-5 beta(H)-structures, a reaction that is catalyzed by a delta 4-3-oxosteroid-5 beta reductase enzyme. This defect resulted in markedly reduced primary bile acid synthesis and concomitant accumulation of delta 4-3-oxo-and allo-bile acids. These findings indicate a pathway in bile acid synthesis whereby side chain oxidation can occur despite incomplete alterations to the steroid nucleus, and lend support for an active delta 4-3-oxosteroid 5 alpha-reductase catalyzing the conversion of the delta 4-3-oxosteroid intermediates to the respective 3 alpha-hydroxy-5 alpha(H)-structures.

Growth hormone insensitivity associated with elevated circulating growth hormone-binding protein in children with Alagille syndrome and short stature.

The purpose of this study was to assess GH sensitivity in children with Alagille syndrome (syndromic intrahepatic bile duct paucity) by examining their response to short term administration of recombinant human GH (rhGH). Serum levels of insulin-like growth factor-I (IGF-I) were low despite elevated overnight integrated serum GH concentrations. Administration of rhGH (0.05 mg/kg.day for 3 days) to four growth-retarded children with Alagille syndrome did not significantly alter the serum concentrations of IGF-I and insulin, blood urea nitrogen, or urinary calcium excretion. In contrast, circulating IGF-I increased 2-fold in two children with Alagille syndrome and normal stature. In the control group, consisting of seven prepubertal children with GH deficiency, the predicted changes in response to rhGH in serum concentrations of IGF-I and insulin, urea nitrogen, and urinary calcium excretion were observed. Serum GH-binding protein levels, measured by a ligand-mediated immunofunctional assay, were significantly higher in children with Alagille syndrome than in children with cirrhosis or GH deficiency. We conclude that growth-retarded children with Alagille syndrome are insensitive to GH. The growth disturbances and metabolic defects may be due in part to failure to increase IGF-I concentrations in response to GH, implying that growth-retarded children with Alagille syndrome may benefit from IGF-I treatment.

Efficacy of cornstarch therapy in type III glycogen-storage disease.

Type III glycogen-storage disease (GSD-III), due to decreased activity of the glycogen debranching enzyme amylo-1,6 glucosidase, may cause hepatic dysfunction, growth failure, and myopathy. The prevention of hypoglycemia by nocturnal intragastric formula infusion has been shown to enhance growth and improve the metabolic abnormalities associated with GSD-III. Cornstarch therapy was effective in preventing hypoglycemia in a few patients with GSD-III who were previously treated with nocturnal enteral formula infusion, but oral cornstarch had not been evaluated as an initial treatment. We studied three patients with GSD-III who exhibited growth failure, elevated serum aminotransferase concentrations, and asymptomatic hypoglycemia. Cornstarch therapy was associated with maintenance of normoglycemia, increased growth velocity, and decreased serum aminotransferase concentrations in all patients. Our experience suggests that cornstarch therapy can be effective as an initial treatment for patients with GSD-III.

Vitamin E deficiency in adults with chronic liver disease.

In order to determine the frequency of vitamin E deficiency in adults with chronic liver disease, we measured serum vitamin E concentrations and calculated the ratio of serum vitamin E to total serum lipids (E/lipids) in forty-two patients with primary biliary cirrhosis (PBC) (Group A), fifteen patients with other forms of chronic liver disease (Group B), and twenty-five healthy adult control subjects (Group C). Although the mean serum vitamin E concentration did not differ significantly among the three groups, the ratio of serum vitamin E/lipids was significantly lower in Group A than Groups B and C. Vitamin E deficiency, as defined by the ratio of serum vitamin E/lipids below 0.8 mg/gm, was present in seven (17%) Group A and one (7%) Group B patients. Serum cholylglycine, sulfated lithocholate conjugates, and bilirubin were significantly higher and the mean duration of symptomatic primary biliary cirrhosis was significantly longer (6.6 vs 2.3 years) in the vitamin E-deficient compared to the vitamin E-sufficient Group A patients. Our study demonstrates that vitamin E deficiency may occur in adults with severe, prolonged cholestatic liver disease.

Oral rehydration in acute infantile diarrhea.

The significance of acute diarrheal illness, a common disorder in infants and children, is presented. Although in developed countries this disease is seldom fatal, it is the second most common reason that children are hospitalized. Methods for managing acute diarrhea and its subsequent dehydration, including intravenous rehydration and refeeding, are discussed, with emphasis placed on the use of oral rehydration solutions.

Expansion of transplanted hepatocytes during liver regeneration.

BACKGROUND: Successful clinical application of hepatocyte transplantation has been limited by poor engraftment of the recipient liver by transplanted hepatocytes. METHODS: To address the hypothesis that liver regeneration induced by an acute hepatotoxic injury promotes expansion of transplanted hepatocytes, we injected beta-galactosidase-labeled hepatocytes intrasplenically into mice 24 hr after treatment with carbon tetrachloride (CCl4) and into untreated controls. RESULTS: Macroscopic examination of whole liver segments identified clusters of transplanted hepatocytes uniformly spread on the capsular surface of the recipient liver and in the liver core following the distribution pattern of portal vein branches. Frozen sections showed that although the degree of initial engraftment of transplanted hepatocytes was similar in CCl4-treated and control livers, there was a fourfold increase of engrafted hepatocytes in CCl4-treated livers 10 days after transplantation which persisted to 28 days. CONCLUSIONS: We conclude that the number of transplanted hepatocytes increases in response to regeneration signal triggered by an acute hepatocyte-specific liver injury.

Successful retreatment of allograft rejection with OKT3.

OKT3 is a murine monoclonal antibody to the CD3 antigen of human T lymphocytes. The production of human antimurine antibodies after treatment with OKT3 has been perceived as a major limitation to its extended use and reuse. Treatment of 142 patients with 168 courses of OKT3 resulted in the development of antimouse antibody in 28% of the patients. Twenty-six patients (16 kidney, 6 liver, 3 heart, 1 pancreas) have been retreated with 27 courses of OKT3. Eighteen patients had no antimurine antibodies present, and the rejection reversal rate was 83% (15/18). Six patients had a low-titer antimurine antibody present, and rejection reversal occurred in 5 (83%). Rejection was not reversed in 2 patients with a high-titer antibody. Development of antimurine antibody was more frequent in renal transplant recipients (33%) than in hepatic (12%) or cardiac transplant recipients (18%). We believe that this reflects the fact that concomitant immunosuppressive therapy is more likely to be reduced during OKT3 therapy in renal transplant recipients than in hepatic or cardiac transplant recipients. Retreatment of patients with no anti-OKT3 antibody resulted in depletion of CD3+ cells from the peripheral blood, but it took longer than in patients being treated with OKT3 for the first time. Similarly, serum OKT3 levels rose more slowly in retreated patients compared to first treatment. In retreating patients with a low-titer antimurine antibody, it often was necessary to increase the dose of OKT3 in order to achieve adequate serum OKT3 levels and to deplete CD3+ cells. De novo antimurine antibody developed in 4 of the 18 (22%) antibody-negative patients who were retreated. In conclusion, retreatment with OKT3 should not be considered unless the antibody status of the patient is known. Development of low-titer antibodies does not preclude successful retreatment with OKT3; however, alternate antirejection therapy should be used in patients with high-titer antimurine responses.

Negative serology for hepatitis A and B viruses in 18 cases of neonatal cholestasis.

Serologic evidence of hepatitis A virus (HAV) or hepatitis B virus (HBV) infection was sought in 14 patients with biliary atresia and in four patients with neonatal hepatitis; maternal serum was also analyzed. Specific sensitive radioimmunoassays were used to detect HBV surface antigen (HBsAg) and antibody (anti-HBs); complement fixation was used to detect antibody to HBV core antigen (anti-HBc). Antibody to HAV (anti-HAV) was assayed by radioimmunoassay, as well as by immune adherence hemagglutination. There was no evidence of active or past HBV infection in any infant or mother studied. All three infants with detectable anti-HAV were born to mothers similarly anti-HAV positive; serial testing of sera from two of these infants documented disappearance of detectable anti-HAV by 9 months of age. It is unlikely, therefore, that either HAV or HBV had an etiologic role in neonatal cholestasis in these patients. The role of other (non-A, non-B) hepatitis viruses or nonviral etiologies must be investigated.

Increased cholesterol and decreased fluidity of red cell membranes (spur cell anemia) in progressive intrahepatic cholestasis.

Progressive hemolytic anemia occurred in a 4 1/2-year-old girl with familial intrahepatic cholestasis; a peripheral smear contained bizarre spiculated "spur" red cells. Analysis of this patient's fresh red cells revealed a 59% increase in cholesterol content with a normal phospholipid content and therefore an increase in the cholesterol/phospholipid molar ratio to 1.35 (normal = 0.92). A similar abnormality of lipid composition was present in serum lipoproteins. The lipid abnormality in red cell membrane was associated with a decrease in membrane fluidity, as assessed by the fluorescence polarization of the hydrophobic probe 1,6-diphenyl-1,3,5-hexatriene. Following incubation with patient's plasma, normal cells acquired a spur-shaped morphology with an associated decrease in osmotic fragility and a 25% increase in cholesterol content. The patient's cells, during incubation with normal plasma, acquired morphologic features of spiculated spherocytes with an increase in osmotic fragility and a 21% decrease in cholesterol content. Chenodeoxycholate and lithocholate were present in markedly elevated concentrations in serum. These studies show that a process identical to spur cell anemia in alcoholic cirrhosis may accompany severe liver disease in children with intrahepatic cholestasis.

Spectrum of Salmonella-associated arthritis.

Arthritis is an uncommon extraintestinal manifestation of Salmonella infection. Three patients with Salmonella-associated arthritis with varying manifestations were seen at Children's Hospital Medical Center in an 11-month period: (1) a 12-year-old girl developed suppurative arthritis due to Salmonella typhimurium that required surgical drainage and prolonged parenteral antibiotic therapy; (2) a 12-year-old girl had migratory polyarthritis following gastrointestinal infection with S typhimurium; the acute synovitis subsided after a six-month period following anti-inflammatory medications; (3) a 14-year-old girl developed conjunctivitis, urethritis, and polyarthritis (Reiter's syndrome) in association with Salmonella gastroenteritis. These patients illustrate the distinct types of arthritis associated with Salmonella gastroenteritis. These patients illustrate that distinct types of arthritis associated with Salmonella, and the association of this organism with both suppurative joint disease and reactive arthritis is reemphasized.

Rapid improvement in the renal tubular dysfunction associated with tyrosinemia following hepatic replacement.

The postoperative management of patients with hereditary tyrosinemia type I (McKusick 27670) following liver transplantation is often complicated by the renal tubular dysfunction associated with this disease. To characterize better the temporal course of the improvement in renal excretory activity following hepatic replacement, renal tubular function and metabolite excretion were studied in a 4-year-old girl with hereditary tyrosinemia during the immediate post-transplantation course. Tubular reabsorption of bicarbonate and phosphate were normal 5 days following transplantation, in contrast to glucosuria, hyperaminoaciduria, and tyrosyluria, which persisted for approximately 3 weeks. After hepatic replacement, serum amino acid concentrations returned to normal and succinylacetone was no longer detected in the urine. This is the third tyrosinemia patient reported to achieve complete resolution of urinary abnormalities following transplantation, and the only patient in whom renal tubular function was formally assessed within the first postoperative week.

Pediatric hepatology. A half-century of progress.

Treating a pediatric patient offers a unique opportunity to develop effective strategies to prevent progressive liver injury and to develop novel therapeutic regimens to reduce the need for OLT. Universal vaccination against hepatitis viruses will prevent cirrhosis and liver cancer. Education and counseling may reduce the incidence of alcoholic liver disease. Precise and early screening for metabolic liver disease and genetic or targeted therapy may prevent disease progression. A retrospective look at the 1983 National Institutes of Health Consensus Conference on Liver Transplantation, after more than 15 years of experience among many centers, indicates that liver transplantation can be effectively used to childhood liver disease. Projections 10 years into the future offer hope that liver transplantation may not be needed in the treatment of certain diseases such as metabolic liver disease and fulminant hepatic failure. Focusing on prevention or treatment of liver disease in early life, thoughtful medical management, precise decision making, and conscientious, creative, and courageous use of nontransplant options, can save both livers and lives.

Persistent enhancement of bile acid synthesis in guinea pigs following stimulation of cholesterol catabolism in neonatal life.

Cholesterol catabolism to bile acids was stimulated in neonatal guinea pigs by feeding 1.11% cholestyramine (CT)-containing diet for 8 weeks. The animals were then switched to standard laboratory diet for an additional 4 weeks. At the end of the laboratory diet period: a) CT-pre-treated guinea pigs continued to excrete significantly higher (p less than 0.05) amounts of bile acids, b) the activity of hepatic 7 alpha-hydroxylase was significantly elevated (p less than 0.01) in CT-pre-treated animals, and c) isolated hepatocytes from CT-pre-treated guinea pigs secreted significantly higher (p less than 0.05) amounts of bile acid when compared to controls during a 4-hour incubation. These data provide biochemical support for our contention that stimulation of cholesterol catabolism during neonatal life can have effects that persist into adult life.

Liver transplantation in children.

Children with end-stage liver disease now have a greater chance of survival through treatment with hepatic transplantation. This article reviews the pediatric liver transplantation process, including selection and evaluation of candidates, operative procedures, postoperative complications, and long-term survival.

Viral hepatitis.

Recent research has led to a greater understanding of the mechanisms and management of the various forms of viral hepatitis. The clinician can rapidly arrive at a precise diagnosis using serologic markers to complement epidemiologic data. In addition, effective immunoprophylaxis is possible; thus disease spread can be minimized.

Viral hepatitis.

Recent research has led to a greater understanding of the mechanisms and management of the various forms of viral hepatitis. The clinician can rapidly arrive at a precise diagnosis using serologic markers to complement epidemiologic data. In addition, effective immunoprophylaxis is possible; thus, disease spread can be minimized.

New methods for assessing liver function in infants and children.

Assessment of liver function in infants and children has traditionally relied on static indices of hepatic structure, cellular integrity, or function and are often based on the release of substances from damaged tissues. There has been a rapid development of dynamic tests based on the measurement of substances metabolized or cleared from blood by the liver. These tests, which have been touted to offer a more precise quantitative estimation of hepatic functional capacity, include the measurement of serum bile acids and the hepatic metabolism of xenobiotic compounds such as caffeine and lidocaine. Serum bile acid measurements appear to be reliable indicators of enterohepatic circulation and may be useful in screening for liver disease. It has been observed that caffeine metabolism is decreased in patients with various forms of liver disease in correlating with disease status. Caffeine has the advantage of being well tolerated when administered orally; the saliva level parallels the serum concentration, making a non-invasive test feasible. Lidocaine is metabolized by oxidative de-ethylation to monoethylglycinexylide (MEGX); analysis of MEGX by common laboratory instrumentation makes rapid evaluation of liver function possible. The MEGX values correlated were with pretransplant liver disease assessment. These tests are currently being evaluated at other centers and, if the initial studies are repeated, they offer the hope for reliable dynamic tests of hepatic function.

Parenteral nutrition and hepatobiliary dysfunction.

Parenteral nutrition associated cholestasis is a condition that challenges even the most astute clinician. The risk:benefit ratio of parenteral nutrition must be individualized for each neonate. The dilemma is based on weighing the risk of progressive cholestasis and its complications against the risk of starvation, malnutrition, and their consequences. Avoiding excessive nutrient infusion and providing even minimal enteral calories may prevent or mitigate cholestasis. Routine monitoring of hepatic function in all neonates receiving parenteral nutrition allows early detection and intervention. Affected infants must be evaluated for treatable causes of neonatal cholestasis. Parenteral nutrition related cholestasis remains a diagnosis of exclusion. Further research is needed to unravel the cause and to define the long-term consequences of parenteral nutrition associated cholestasis.

Long-term survival after liver transplantation.

BACKGROUND: Liver transplantation (LT) remains a high-risk operation, especially during the first months after LT when technical complications and preexisting illness exert their influence on survival. However, there are late deaths. The authors have reviewed their experience to identify factors impacting on long-term survival. METHODS: A total of 150 patients who had undergone liver transplantation over an 11-year period were reviewed. Thirty-three patients died after LT (22%). Of these, 18 of 33 (55%) died in the first 3 postoperative months. One hundred thirty-two patients survived beyond 3 months, and 15 patients (11%) suffered late deaths. This review concentrates on the latter group. RESULTS: The primary cause of death was sepsis in 11 of 15 (73%). In two, sepsis complicated retransplantation in chronically debilitated patients. Two additional patients had late-presenting postoperative complications (bile leak or abscess, intestinal obstruction with perforation). In two cases, pneumocystis carinii pneumonia occurred; noncompliance or unplanned discontinuation of prophylaxis was directly responsible. Multiple organ system failure from presumed immunoincompetence developed in four patients; one had undergone bone marrow transplantation for aplastic anemia (AA) after fulminant hepatic failure (FHF). Lymphoproliferative disease (LPD) was the cause of death in 3 of 15 cases (20%). In only three cases was the cause of death related to the patient's primary disease (chronic hepatitis, Alper's syndrome or seizures, and AA with FHF). Pretransplant diagnosis, and UNOS status at the time of LT did not influence the long-term survival. CONCLUSIONS: Long-term survival in patients who have undergone LT was compromised by immunosuppressive complications and sepsis. Early mortality factors, such as UNOS status, age at LT, primary diagnosis, and technical complications do not predict late deaths. In children who adhere to their medical regimen and have good initial allograft function, late postoperative infection, especially with Ebstein-Barr virus, accounts for most of the late mortality. Improved and decreased immunosuppression may further improve these long-term results.

Segmental orthotopic hepatic transplantation as a means to improve patient survival and diminish waiting-list mortality.

Pediatric liver transplantation continues to be limited by the availability of suitable liver donors, a factor that restricts programmatic development and ultimately contributes to death on the recipient waiting list. We report the application of segmental liver transplantation as a technique to address both these problems as well as improving the outcome of the child undergoing the transplant procedure. Since 1986, 37 children have undergone orthotopic liver transplantation. Twenty-three children have received whole-organ grafts; 81% survived. Of those receiving whole-organ grafts, 15% had arterial thrombotic complications and 23% required retransplantation. More importantly, 29% of those children listed for transplantation died while waiting for a donor organ to become available, with a mean interval of 1.7 months (range, 2 days to 4.5 months). Since July 1988, segmental liver transplantation has been a component of our therapeutic armamentarium, and of the past 20 liver recipients, 16 have received a left lobe segmental graft. The results of the segmental transplant series have shown striking improvements. First, no child has died while awaiting donor organ availability. Second, segmental liver recipient survival is equivalent to that of whole-organ graft recipients (81%). Third, hepatic arterial thrombosis, especially a problem in high-risk infant transplants, was reduced by this technique (5%). Retransplantation due to graft complications has not increased (21%). These data suggest a vital role for segmental liver transplantation not only as a remedial salvage procedure for the critically ill child, but also as a primary transplant option.