Suppression of bile acid synthesis as a tipping point in the disease course of primary sclerosing cholangitis.
JHEP Rep
; 4(11): 100561, 2022 Nov.
Article
em En
| MEDLINE
| ID: mdl-36176935
ABSTRACT
Background & Aims:
Farnesoid X receptor (FXR) agonists and fibroblast growth factor 19 (FGF19) analogues suppress bile acid synthesis and are being investigated for their potential therapeutic efficacy in cholestatic liver diseases. We investigated whether bile acid synthesis associated with outcomes in 2 independent populations of people with primary sclerosing cholangitis (PSC) not receiving such therapy.Methods:
Concentrations of individual bile acids and 7α-hydroxy-4-cholesten-3-one (C4) were measured in blood samples from 330 patients with PSC attending tertiary care hospitals in the discovery and validation cohorts and from 100 healthy donors. We used a predefined multivariable Cox proportional hazards model to evaluate the prognostic value of C4 to predict liver transplantation-free survival and evaluated its performance in the validation cohort.Results:
The bile acid synthesis marker C4 was negatively associated with total bile acids. Patients with fully suppressed bile acid synthesis had strongly elevated total bile acids and short liver transplantation-free survival. In multivariable models, a 50% reduction in C4 corresponded to increased hazards for liver transplantation or death in both the discovery (adjusted hazard ratio [HR] = 1.24, 95% CI 1.06-1.43) and validation (adjusted HR = 1.23, 95% CI 1.03-1.47) cohorts. Adding C4 to established risk scores added value to predict future events, and predicted survival probabilities were well calibrated externally. There was no discernible impact of ursodeoxycholic acid treatment on bile acid synthesis.Conclusions:
Bile acid accumulation-associated suppression of bile acid synthesis was apparent in patients with advanced PSC and associated with reduced transplantation-free survival. In a subset of the patients, bile acid synthesis was likely suppressed beyond a tipping point at which any further pharmacological suppression may be futile. Implications for patient stratification and inclusion criteria for clinical trials in PSC warrant further investigation. Laysummary:
We show, by measuring the level of the metabolite C4 in the blood from patients with primary sclerosing cholangitis (PSC), that low production of bile acids in the liver predicts a more rapid progression to severe disease. Many people with PSC appear to have fully suppressed bile acid production, and both established and new drugs that aim to reduce bile acid production may therefore be futile for them. We propose C4 as a test to find those likely to respond to these treatments.
7α-Hydroxy-4-cholesten-3-one; AOM, AmsterdamOxford model; ASBT, apical sodium-dependent bile acid cotransporter; Biliary disease; C4; C4, 7α-hydroxy-4-cholesten-3-one; CYP7A1, cytochrome P450 family 7 subfamily A member 1; Cholestasis; Cholestatic liver disease; FGF19, fibroblast growth factor 19; FXR, farnesoid X receptor; GUDCA, glycooursodeoxycholic acid; HR, hazard ratio; IBAT, ileal bile acid transporter; Liver transplantation; Liver transplantation-free survival; MELD, model for end-stage liver disease; PBC, primary biliary cholangitis; PSC, primary sclerosing cholangitis; STROBE, Strengthening the Reporting of Observational Studies in Epidemiology; TUDCA, tauroursodeoxycholic acid; UDCA, ursodeoxycholic acid; UPLC-MS/MS, ultraperformance liquid chromatographytandem mass spectrometry; Ursodeoxycholic acid; c-index, concordance index; liver
Texto completo:
1
Coleções:
01-internacional
Base de dados:
MEDLINE
Tipo de estudo:
Prognostic_studies
Idioma:
En
Revista:
JHEP Rep
Ano de publicação:
2022
Tipo de documento:
Article
País de afiliação:
Noruega