Non-invasive urinary metabolomic profiles discriminate biliary atresia from infantile hepatitis syndrome.

INTRODUCTION: Neonatal cholestatic disorders are a group of hepatobiliary diseases occurring in the first 3 months of life. The most common causes of neonatal cholestasis are infantile hepatitis syndrome (IHS) and biliary atresia (BA). The clinical manifestations of the two diseases are too similar to distinguish them. However, early detection is very important in improving the clinical outcome of BA. Currently, a liver biopsy is the only proven and effective method used to differentially diagnose these two similar diseases in the clinic. However, this method is invasive. Therefore, sensitive and non-invasive biomarkers are needed to effectively differentiate between BA and IHS. We hypothesized that urinary metabolomics can produce unique metabolite profiles for BA and IHS. OBJECTIVES: The aim of this study was to characterize urinary metabolomic profiles in infants with BA and IHS, and to identify differences among infants with BA, IHS, and normal controls (NC). METHODS: Urine samples along with patient characteristics were obtained from 25 BA, 38 IHS, and 38 NC infants. A non-targeted gas chromatography-mass spectrometry (GC-MS) metabolomics method was used in conjunction with orthogonal partial least squares discriminant analysis (OPLS-DA) to explore the metabolomic profiles of BA, IHS, and NC infants. RESULTS: In total, 41 differentially expressed metabolites between BA vs. NC, IHS vs. NC, and BA vs. IHS were identified. N-acetyl-D-mannosamine and alpha-aminoadipic acid were found to be highly accurate at distinguishing between BA and IHS. CONCLUSIONS: BA and IHS infants have specific urinary metabolomic profiles. The results of our study underscore the clinical potential of metabolomic profiling to uncover metabolic changes that could be used to discriminate BA from IHS.

[The reassessment of the diagnostic value of 24-hour urinary copper excretion in children with Wilson's disease].

OBJECTIVE: To reassess the diagnostic value of 24 hour urinary copper excretion in children with Wilson disease (WD). METHODS: From July 2005 to June 2007, inpatients over three years old in a pediatric liver center were assigned into WD and non-WD group. RESULTS: 94 patients, including 26 cases in WD and 68 in non-WD group, were enrolled in this study. The median of 24 h urinary copper excretion was 98.5 microg in WD group and 25.8 microg in the non-WD group (Z = -6.111, P equal to 0.000). The area under receiver operator curve (ROC) was 0.909 (95% CI: 0.839-0.979, P equal to 0.000). The sensitivity, specificity, accuracy, positive predictive value and negative predictive value were 84.6%, 91.2%, 89.4%, 78.6% and 93.9% respectively using 52.0 ug as a cutoff value, and 50.0%, 97.1%, 84.0%, 86.7% and 83.5% using 100 microg as a cutoff value. The goodness of fitness of 52 microg criteria was significantly higher than 100 microg criteria (kappacoefficient 0.760, 0.541 respectively, P equal to 0.000). CONCLUSION: Comparing to 100, 52 microg of 24 h urinary copper excretion as a cutoff value significantly improves the sensitivity and accuracy for diagnosing WD in children.

Urinary excretion of liver fatty acid-binding protein in health-check participants.

BACKGROUND: Messenger RNA of liver fatty acid-binding protein (L-FABP) is expressed in proximal tubules of the kidney, and a certain amount is excreted into urine. We analyzed factors relating to the urinary L-FABP excretion in health-check participants. METHODS: We measured L-FABP in the first morning urine by ELISA in 715 men and 193 women 30-79 years of age who entered a 2-day hospitalized health checkup program. In addition to the routine physical examination and laboratory tests, plasma high-sensitivity C-reactive protein (HSCRP) was assayed. RESULTS: In 150 healthy subjects, urinary L-FABP averaged 3.6 +/- 0.2 microg/g creatinine, whereas the values were significantly increased in patients with hypertension (5.2 +/- 0.4, P = 0.010), diabetes mellitus (5.5 +/- 0.5, P < 0.001), and chronic hepatitis (5.8 +/- 1.0, P = 0.022). Urinary L-FABP excretion was significantly greater in women than in men when the value was related to creatinine. In regression analysis in men, urinary L-FABP was positively correlated with fasting plasma glucose (r = 0.103, P = 0.033) and plasma HSCRP (r = 0.135, P = 0.006). CONCLUSIONS: It is suggested that renal production and urinary excretion of L-FABP are increased in situations in which arteriosclerosis is promoted, such as hypertension, diabetes mellitus, and cardiovascular inflammation.

A paucity of unusual trihydroxy bile acids in the urine of patients with severe liver diseases.

To clarify the relationship between the occurrence of unusual trihydroxy bile acids, namely hyocholic acid, ursocholic acid (UCA), and omega-muricholic acid (omega-MCA) in urine and liver disease severity, urinary bile acids were analyzed by gas-liquid chromatography in acute and late phases of acute hepatitis and before and after ursodeoxycholic acid (UDCA) loading in healthy adults and liver cirrhosis patients. In 11 patients with acute hepatitis, the occurrence rates and amounts of unusual trihydroxy bile acids were increased in the late (recovery) phase, as compared with those in the early phase. In 10 patients with severe acute hepatitis who had prothrombin times exceeding 16 seconds, these bile acids had completely disappeared from the urine in the early phase but reappeared in the late phase in those who had a good outcome, though never in a patient who died. After UDCA administration for a week, the amounts of unusual bile acids, especially UCA and omega-MCA, which are thought to be synthesized through 12 alpha- and 6 alpha-hydroxylations, respectively, from UDCA, were clearly increased in 10 healthy adults but only slightly changed in 10 patients with liver cirrhosis. In conclusion, hepatic hydroxylations of dihydroxy bile acids as a detoxification reaction were impaired in severe liver diseases, which may play a role in the intensification and perpetuation of hepatocellular injuries.

Direct enzymatic assay of urinary sulfated bile acids to replace serum bilirubin testing for selective screening of neonatal cholestasis.

Direct enzymatic assay of urinary sulfated bile acids is a sensitive, rapid, minimally invasive, and convenient method of detecting cholestasis in young infants. It may replace measurement of serum direct bilirubin for selective screening for biliary atresia and neonatal hepatitis syndrome at 1 month of age.

Increased urinary endothelin excretion in patients with liver cirrhosis.

The urinary endothelin level in patients with chronic liver disease was determined in order to explore its possible involvement in renal function. The plasma endothelin level was significantly higher in patients with liver cirrhosis (LC) than in those with chronic hepatitis (CH) or in control patients (C). Similarly, urinary endothelin excretion in LC was significantly increased, compared with CH and C. Urinary endothelin demonstrated a significant positive correlation with creatinine clearance. The ratio of endothelin clearance/creatinine clearance did not differ statistically among the three groups. Urinary sodium excretion in LC was positively correlated with plasma endothelin, but not with urinary endothelin. Urinary endothelin excretion demonstrated a significant negative correlation with urinary kallikrein in LC. The present data suggest that increased urinary endothelin excretion in cirrhotic patients primarily depends upon elevated plasma levels of endothelin, but not renal production. Also, a possible link between endothelin and the kallikrein-kinin system in liver cirrhosis is indicated.

Guanidino compounds in serum and urine of cirrhotic patients.

To investigate the metabolic relationship between urea and guanidinosuccinic acid (GSA), we determined the levels of the guanidino compounds, including GSA, and urea in serum and urine of cirrhotic patients. Linear correlation studies between serum urea and GSA levels were performed. Good positive linear correlation coefficients were found in the Child-Turcotte C subgroup (r = .847, P < .001) and in the total subgroup including B and C patients (r = .848; P < .0001). Serum guanidinoacetic acid levels were significantly increased in the Child-Turcotte C subgroup (P < .0001 for men and P < .001 for women). In contrast, GSA levels were significantly (P < .0001) decreased in the three studied subgroups. Similar results were found for urinary GSA excretion levels. Within each subgroup, serum and urinary GSA levels were significantly lower in patients with alcohol-induced cirrhosis than in nonalcoholic cirrhotic patients. Similar results were obtained for urea. The findings in cirrhotic patients clearly demonstrate a metabolic relationship between urea and GSA. They also show that urea and GSA biosynthesis is significantly lower in cirrhotic patients with an alcoholic origin than in cirrhotic patients with a nonalcoholic origin.

Latent distal renal tubular acidosis (dRTA) in primary biliary cirrhosis (PBC) and chronic autoimmune hepatitis (CAH).

In an attempt to evaluate the latent distal renal tubular acidosis (dRTA7) in patients with primary biliary cirrhosis (PBC), and chronic autoimmune hepatitis (CAH), and differences between them in relation to the sodium urinary excretion ([Na]u), thirty four patients divided in two groups were studied. Group A: 17 patients who fulfilled criteria for PBC diagnosis (clinical and humoral evidence antimitochondrial antibody titles of 1/80 or above by indirect immunofluorescence technique, and liver biopsy). Group B: 17 patients who fulfilled criteria for CAH diagnosis (clinical and humoral evidence, antinuclear and smooth muscle antibody titles of 1/80 or above and liver biopsy). Patients with ascitis and/or edema were excluded from the study. Ability to acidify urine was evaluated by gradient between pC02 in urine and blood (U-BpC02) after alkali infusion. Five patients in Group A (29.4%7) and six in Group B(35.2%) had dRTA, (p = 0.49). When analyzing patients with dRTA in both groups, the mean [Na]u in Group A was 152.2 +/- 33.8, versus 50.8 +/- 8.1 mEq/l, in Group B. (p = 0.00016). We concluded that the prevalence of dRTA was similar in patients with PBC and CAH but the urinary acidifications impairment of the former did not correlate with [Na]u, as it did with the latter.

Latent distal renal tubular acidosis (dRTA) in primary biliary cirrhosis (PBC) and chronic autoinmune hepatitis (CAH)

In an attempt to evaluate the latent distal renal tubular acidosis (dRTA7) in patients with primary biliary cirrhosis (PBC), and chronic autoinmmune hepatitis (CAH), and differences between them in relation to the sodium urinary excretion ([a]u), thirty four patients divided in two groups were studied. Group A: 17 patients who fullfilled criteria for PBC diagnosis (clinical and humoral and liver biopsy). Group B: 17 patients who fullfilled criteria for CAH diagnosis (clinical and humoral evidence, antinuclear and smooth muscle antibody tiles of 1/80 or above and liver biopsy). Patients with ascitis and/or edema were excluded form the study. Ability to acidify urine was evaluated by gradient between pCO2 in urine and blood (U-BpC02) after alkali infusion. Five patients with dRTA in both groups, the mean [Na]u in Group A was 152.2 ñ 33.8, versus 50.8 ñ 8.1 mEq/l, in Group B. (p=0.00016). We concluded that the prevalence of dRTA was similar en patiens with PBC and CAH but the urinary acidifications impairment of the former did not correlate with [Na]u, as it did whit the latter

Latent distal renal tubular acidosis (dRTA) in primary biliary cirrhosis (PBC) and chronic autoinmune hepatitis (CAH)

In an attempt to evaluate the latent distal renal tubular acidosis (dRTA7) in patients with primary biliary cirrhosis (PBC), and chronic autoinmmune hepatitis (CAH), and differences between them in relation to the sodium urinary excretion ([a]u), thirty four patients divided in two groups were studied. Group A: 17 patients who fullfilled criteria for PBC diagnosis (clinical and humoral and liver biopsy). Group B: 17 patients who fullfilled criteria for CAH diagnosis (clinical and humoral evidence, antinuclear and smooth muscle antibody tiles of 1/80 or above and liver biopsy). Patients with ascitis and/or edema were excluded form the study. Ability to acidify urine was evaluated by gradient between pCO2 in urine and blood (U-BpC02) after alkali infusion. Five patients with dRTA in both groups, the mean [Na]u in Group A was 152.2 ñ 33.8, versus 50.8 ñ 8.1 mEq/l, in Group B. (p=0.00016). We concluded that the prevalence of dRTA was similar en patiens with PBC and CAH but the urinary acidifications impairment of the former did not correlate with [Na]u, as it did whit the latter (AU)

Large amounts of 1 beta-hydroxylated bile acids in urine during taurine therapy.

The management of infants with cholestasis remains a difficult challenge. On the hypothesis that taurine is effective in treating neonatal cholestasis, taurine (1 g/day, per os) was administered to 2 patients with neonatal hepatitis and the bile acids were analyzed using gas chromatography-mass spectrometry (GC-MS). The serum levels of bilirubin and bile acids were significantly decreased by taurine. Before the treatment, cholic acid (CA) and chenodeoxycholic acid (CDCA) were predominant (79.2% in both patients) in the urine. There was a significant elevation of 1 beta-hydroxylated bile acids (1 beta BA), especially 1 beta, 3 alpha, 7 alpha, 12 alpha-tetrahydroxy-5 beta-cholan-24-oic acid (CA-1 beta-ol), in urine collected during the taurine therapy, and 1 beta BA became predominant (57.7-78.3%). Therefore, increased amounts of urine 1 beta BA were excreted during taurine administration. Taurine therapy is recommended, because it might be effective for treating neonatal cholestasis.

Altered bile acid metabolism in liver disease: concurrent occurrence of C-1 and C-6 hydroxylated bile acid metabolites and their preferential excretion into urine.

C-1 and C-6 hydroxylated bile acid metabolites in various biological specimens from subjects with liver disease (cholestasis, liver cirrhosis, chronic hepatitis, acute hepatitis) were determined by gas-liquid chromatography-mass spectrometry. Five C-1 hydroxylated bile acids and nine C-6 hydroxylated bile acids were identified in the urine studied; 1 beta,3 alpha,12 alpha-trihydroxy-, 1 beta,3 alpha,7 alpha-trihydroxy-, 1 beta,3 alpha,7 alpha,12 alpha-tetrahydroxy-, 3 alpha,6 alpha,7 alpha-trihydroxy-, and 3 alpha,6 alpha,7 alpha,12 alpha-tetrahydroxy-5 beta-cholanoic acids were found as the major components. Most of the 1 beta- and 6 alpha-hydroxylated bile acids were excreted into urine in the nonsulfate-nonglucuronide form. The amounts in the urine were greater than those found in the bile, portal and peripheral venous sera, and liver specimens. The biliary excretion and hepatic extraction of 1 beta-hydroxylated metabolites were more impaired and less efficient than for cholic acid. These findings suggested that hepatic 1 beta- or 6 alpha-hydroxylation of bile acids occurred concurrently in the patients with liver disease and that the resulting hydroxylated metabolites were efficiently excreted in the nonsulfate-nonglucuronide form into urine rather than into bile.

Urinary hydroxyproline and hydroxylysine excretions in relation to hepatic hydroxyproline content in chronic liver disease.

In patients with or without various chronic liver diseases, the total urinary excretion of hydroxyproline and hydroxylysine and the hepatic content of hydroxyproline were examined. In 7 patients without liver disease, the urinary excretion of hydroxyproline and hydroxylysine were 10.3 +/- 1.5 and 1.31 +/- 0.21 mmol/mol creatinine, respectively, and the hepatic content of hydroxyproline was 4.9 +/- 0.6 mumol/g of wet liver. In 33 patients with liver disease, the urinary excretion of hydroxyproline and hydroxylysine and the hepatic content of hydroxyproline were increased in proportion to the severity of liver disease. The hepatic content of hydroxyproline showed a significant correlation with the urinary excretion of hydroxyproline and hydroxylysine (r = +0.406 and r = +0.531, respectively). These results suggest that the study of urinary hydroxyproline and hydroxylysine excretion may yield useful information on the metabolism of hepatic collagen in chronic liver disease. Moreover, urinary hydroxylysine excretion seemed to be a better index of hepatic collagen metabolism than urinary hydroxyproline excretion; perhaps urinary hydroxylysine excretion is not much affected by dietary collagen intake.

Spontaneous hepatitis in Long-Evans rats. A potential animal model for fulminant hepatitis in man.

Spontaneous hepatitis associated with severe jaundice occurred in 90% of an inbred strain of Long-Evans rats. The rapidly progressive syndrome was characterized by abrupt onset, hyperbilirubinemia and increased serum levels of glutamic oxaloacetic transaminase and glutamic pyruvic transaminase, associated with massive and multifocal necrosis of the liver. This strain should provide a useful animal model for analysis of the pathogenesis of fulminant hepatitis in humans.

Urinary neopterin levels in acute viral hepatitis.

Elevated neopterin levels in blood or urine have been shown to be a marker for the activation of cell-mediated immunity in vitro and in vivo. To evaluate whether neopterin levels are elevated in patients with acute viral hepatitis, we measured urinary levels in 13 patients with hepatitis A, 26 with hepatitis B, 12 with non-A, non-B hepatitis, 8 with jaundice and/or cholestasis due to biliary and pancreatic disorders and 3 with alcoholic hepatitis and in 62 apparently healthy HBsAg carriers. Neopterin levels in patients with virus-induced hepatitis were significantly higher than those in patients with other diagnoses. Urinary neopterin levels were above normal in 49 of 51 patients with viral hepatitis and elevations during the course of hepatitis showed a pattern similar to that of the usual liver biochemical tests, suggesting that neopterin levels were related to the clinical activity of the viral disease. In patients with nonviral biliary and hepatic disorders, neopterin levels were usually normal and did not correlate with other liver biochemical tests. These findings suggest that cell-mediated immune mechanisms are activated during viral hepatitis and that neopterin measurement may be of value as an additional surrogate marker for non-A, non-B hepatitis.

Determinación de substancias reductoras en la orina como método inicial para el diagnóstico temprano de galactosemia e intolerancia hereditaria a la fructuosa en niños con hepatitis / Determination of the reducing substances in the urine as a diagnostic method for galactosemia and fructose intolerance in children with neonatal hepatitis

La determinación de substancias reductoras en orina, se realizó en 40 niños con hepatitis neonatal utilizando, para ello, la prueba de Clinitest y Benedict. Sólo en dos niños se obtuvo como resultado una reacción falsa positiva. Se concluye que el clinitest es un método sencillo, práctico, económico y de gran utilidad para la detección temprana e inicial de galactosemia e intolerancia a la fructuosa. Las que deberán corroborarse en caso necesario posteriormente con un estudio metabólico completo