Preemptive liver transplantation is essential for patients with severe BSEP deficiency.

Background: Primary hyperoxaluria (PH) is a heterogeneous disease with variable age of onset and inconsistent progression into renal failure (ESRF). Aims: In 1994 we initiated a survey within our Pediatric Nephrology working group to ascertain epidemiologic data and current practices. Updates were performed in 2000 and 2004. Results: Diagnosis of PH was made in 65 patients (42 with PH type I, 3 with PH type II, 12 unclassified and 8 reported dead), which suggests a minimum prevalence of 0.7 per 1 million of the population. First symptoms were urolithiasis, nephrocalcinosis, urinary tract infection or hematuria. Diagnosis was often delayed and was made only in ESRF in 11% of patients. Measurement of urine metabolites or plasma oxalate in ESRF was performed in 76 and 57%, respectively. Determination of enzyme activity in liver biopsy (55% overall) and mutation analysis have increasingly been performed since 2000 (84.2 and 51%). Treatment included high fluid intake, pyridoxine, citrate and magnesium preparations. Pyridoxine response was reported in 21% of patients. No genotype/phenotype correlation was seen. Most patients (39) do not require renal replacement therapy, 5 patients receive chronic hemodialysis. Preemptive liver (n = 5) and combined liver-kidney transplantation (n = 9) were the preferred transplantation procedures. Conclusion: Despite increasing knowledge and awareness, diagnosis of PH is still too often delayed and diagnosis only made in ESRF. Most German patients, however, do currently not require renal replacement therapy. Genotype/phenotype correlations were not found. Combined liver kidney transplantation is the preferred procedure, but has its specific risks. Additional treatment options are clearly needed.

25-hydroxy VD insufficiency is known in children undergoing LT but the serial post-transplant VD course and supplementation modalities in the peri-transplant period are lacking. We aimed to determine the pre-VD status and the post-transplant VD status course following VD supplementation and to elucidate its relationship with post-transplant outcome parameters such as infection and survival. Pre- and post-VD levels were monitored in parallel with interventions to adjust VD levels in LT patients. VD status was categorized as circulating levels <30-21ng/ml (insufficiency), 20-10ng/ml (deficiency), and <10ng/ml (severe deficiency). Patients received stoss (300000IU) VD3 within the pretransplant period if serum levels were <20ng/ml. 135 transplanted children were included. The age at LT was 22months (IQR: 8-60). The pretransplant median VD level was 14ng/ml. Despite stoss dose, post-transplant median VD level was 1.8ng/ml (day one), 4ng/ml (week one), 19ng/ml (month one), 33ng/ml (month three), 38ng/ml (months 6-12), and 40ng/ml (month 24). After 6months, VD status reached >30ng/ml in 98% of patients. Only at pre-LT, higher infection rate (18.7%) in the severe VD deficiency group was observed compared to the VD deficiency group (2.9%, p=.04). Survival was not affected by serum VD levels. VD levels fell substantially after LT but are rectifiable by stoss dose, which was well tolerated. Only the infection rate was associated with the VD status.

To advance our understanding of monogenic forms of intrahepatic cholestasis. Analyses included participants with pathogenic biallelic mutations in adenosine triphosphate (ATP)-binding cassette subfamily B member 11 (ABCB11) (bile salt export pump; BSEP) or adenosine triphosphatase (ATPase) phospholipid transporting 8B1 (ATP8B1) (familial intrahepatic cholestasis; FIC1), or those with monoallelic or biallelic mutations in adenosine triphosphate (ATP)-binding cassette subfamily B member 4 (ABCB4) (multidrug resistance; MDR3), prospectively enrolled in the Longitudinal Study of Genetic Causes of Intrahepatic Cholestasis (LOGIC; NCT00571272) between November 2007 and December 2013. Summary statistics were calculated to describe baseline demographics, history, anthropometrics, laboratory values, and mutation data. Ninety-eight participants with FIC1 (n = 26), BSEP (n = 53, including 8 with biallelic truncating mutations [severe] and 10 with p.E297G or p.D482G [mild]), or MDR3 (n = 19, including four monoallelic) deficiency were analyzed. Thirty-five had a surgical interruption of the enterohepatic circulation (sEHC), including 10 who underwent liver transplant (LT) after sEHC. Onset of symptoms occurred by age 2 years in most with FIC1 and BSEP deficiency, but was later and more variable for MDR3. Pruritus was nearly universal in FIC1 and BSEP deficiency. In participants with native liver, failure to thrive was common in FIC1 deficiency, high ALT was common in BSEP deficiency, and thrombocytopenia was common in MDR3 deficiency. sEHC was successful after more than 1 year in 7 of 19 participants with FIC1 and BSEP deficiency. History of LT was most common in BSEP deficiency. Of 102 mutations identified, 43 were not previously reported. In this cohort, BSEP deficiency appears to be correlated with a more severe disease course. Genotype-phenotype correlations in these diseases are not straightforward and will require the study of larger cohorts.

<h3>Introduction</h3> Vitamin D deficiency and reduced BMD are highly prevalent in patients with advanced chronic liver disease. For bisphosphonate treatment for osteoporosis to be effective vitamin D levels must be replete. Moreover, vitamin D deficiency has been associated with an increased risk of infections and increased rejection rates following liver transplantation. The optimal dose and route of vitamin D replacement in cirrhosis is unknown. BSG guidance currently recommends 800 IU/day orally for all patients with cirrhosis/cholestatic liver disease. <h3>Methods</h3> Retrospective review of 218 cirrhotic patients undergoing evaluation for liver transplant between 2016 and 2017. Vitamin D 'severe deficiency' was defined as &lt;25 ng/ml, 'deficiency' 25–50 ng/ml and normal &gt;50 ng/ml. Response to oral vitamin D therapy was recorded. <h3>Results</h3> Out of 218 patients, 128/218 (59%) had low Vitamin D levels with 25% (n=55) 'severely deficient' and 33% (n=73) 'deficient'. Overall 33 patients with levels&lt;50 ng/ml (52%), and 31 patients (48%) with levels&gt;50 ng/ml received replacement therapy. (p=0.86) Median daily dose of Vitamin D replacement was 2800 units/day (IQR 800–2800) in &lt;25 ng/ml group, 2860 units/day (IQR 800–2800) in &lt;50 ng/ml group and 800 units/day (IQR 800–2000) in &gt;50 ng/dl group. No significant difference in dosing between these groups (p=0.12). Data on vitamin D levels pre and post 3 months of treatment with Vitamin D therapy were available in 58 patients. Patients received either 400IU/day (n=6), 800–1600IU/day (n=28) or &gt;1600 IU/Day (n=24). Median delta change in vitamins D levels in the 3 groups were −3 ng/ml, −1 ng/ml and 12 ng/ml over the 3 month treatment period. An average daily dose of &gt;1600 IU/day Resulted in a significantly greater increase in Vitamin D levels when compared to doses&lt;1600 IU/day (p=0.01), albeit still sub optimal with only a median increase of 12 ng/ml. When those patients with Vitamin D levels of &lt;50 ng/ml were reviewed in isolation (n=29), 82% failed to augment vitamin D levels to within the normal range &gt;50 ng/dl and no significant difference was found between dosages of vitamin D administered. <h3>Conclusion</h3> Vitamin D deficiency is prevalent, affecting over 50% of patients with advanced cirrhosis. Oral vitamin D replacement therapy is ineffective in cirrhotics at repleting stores over a 3 month period irrespective of dose given. Future evaluation of efficacy of IM administration in this unique cohort of patients is urgently needed to evaluate if this allows normalisation of Vitamin D levels.

This study describes the neurodevelopmental outcome of children with urea cycle disorders (UCD) and organic acidemias (OA) preliver transplant (LT), 1-year, and 3-years post-LT. We performed a retrospective chart review of children with OA or UCD transplanted between January 2014 and December 2021. Standardized motor and cognitive assessment scores were collected from children who had ≥1 motor/cognitive assessment at any timepoint. Pre-LT brain magnetic resonance imaging (MRI) was graded. Associations between demographic/medical variables and neurodevelopmental outcomes were explored. Twenty-six children (64% male) underwent LT at a median age of 1.4 (interquartile range 0.71, 3.84) years. Fifteen (58%) had a UCD diagnosis, 14 (54%) required dialysis for hyperammonemia, and 10 (42%) had seizures typically around diagnosis. The proportion of children with gross motor scores >1 standard deviation (SD) below the mean increased across timepoints, and ≥50% demonstrated general intellect scores >2 SD below the mean at each timepoint. The following significant associations were noted: UCD diagnoses with lower general intellect scores (p = 0.019); arginosuccinate lyase deficiency diagnosis with lower visual motor scores at 3-years post-LT (p = 0.035); a history of seizures pre-LT with lower general intellect (>2SD below the mean) at 3-years post-LT (p = 0.020); dialysis pre-LT with lower motor scores (>1 SD below the mean) at 1-year post-LT (p = 0.039); pre-emptive LT with higher general intellect scores at 3-years post-LT (p = 0.001). MRI gradings were not associated with developmental scores. In our single centre study, children with UCD or OA had a higher prevalence of developmental impairment post-LT compared to population norms. Earlier screening, pre-emptive transplant, and rehabilitation may optimize long-term outcomes.

A small-for–gestational age term female neonate born at 38 weeks and 4 days of gestation is transferred to a level 4 NICU at 11 days of age for further evaluation and treatment of bilateral parenchymal brain hemorrhages, culture-negative meningitis, history of thrombocytopenia, coagulopathy, and transaminase elevation. The infant was born via cesarean section to a 31-year-old gravida 2, para 2-0-0-2 healthy mother due to decreased fetal movement and non-reassuring fetal heart tones. The pregnancy was complicated by gestational hypertension and suspected fetal 47,XXX chromosomes. Maternal medications during pregnancy included prenatal vitamins. Maternal prenatal infection screening results were unremarkable. Membranes ruptured at the time of delivery with thick meconium. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. The infant’s birthweight was 2,419 g.Physical examination on admission shows her weight to be 2,580 g (1.33 percentile). She is active and not ill-appearing, with a respiratory rate of 37 breaths/min, heart rate 197 beats/min, temperature 98.2°F (36.8°C), blood pressure of 98/72 mm Hg, and transcutaneous oxygen saturation of 91% in room air. The infant is noted to have a soft systolic murmur, adequate air entry bilaterally, soft non-distended abdomen with absent organomegaly, low central tone, mild extremity hypertonia, and small flat hemangioma on the right abdomen.During her initial NICU hospitalization, a chromosomal abnormality is confirmed. Magnetic resonance imaging of the brain on day 3 after birth shows extensive parenchymal hemorrhages, both ischemic and hemorrhagic in appearance. Serial head ultrasonography shows hemorrhagic progression with concurrently developing hydrocephalus. On day 9 after birth, the infant starts having intermittent episodes of fever. She develops transaminitis (with a maximum alanine aminotransferase of 754 U/L [12.6 μkat/L] and aspartate aminotransferase 444 U/L [7.4 μkat/L], transient with spontaneous improvement) with thrombocytopenia (85 × 103/μL [85 × 109/L]), hyperfibrinogenemia (nadir <69 mg/dL [0.69 g/L]), and elevated international normalized ratio (INR; 1.84). She receives antibiotic therapy for presumptive clinical bacterial meningitis. Blood and cerebrospinal fluid cultures are negative.After transfer to the level 4 NICU, an extensive evaluation for infectious diseases is performed, which includes urine and blood polymerase chain reaction (PCR) for cytomegalovirus, immunoglobulin (Ig) G and IgM testing for lymphocytic choriomeningitis virus, treponemal antibody testing, RNA testing for human immunodeficiency virus, IgA/IgM/IgG testing for Toxoplasma, serum enterovirus testing, parechovirus PCR testing, and serum parvovirus PCR testing. Complete eye examination findings are normal. Initial echocardiography shows a patent foramen ovale versus atrial septal defect. During hospitalization, she has both bleeding and thrombotic complications including a hematoma on the periumbilical abdomen after umbilical venous catheter placement, ecchymosis on her abdominal flanks after lumbar puncture positioning on day 19 after birth, a right renal vein thrombosis (RVT) on day 21, and an extensive purpura in the suprapubic region on day 27 (Fig 1).This case describes progressive coagulopathy in a term female infant with XXX karyotype, with a new skin lesion that developed on day 27 after birth; the NICU course was complicated by bleeding dyscrasia with intraparenchymal bleeding, thrombocytopenia, low fibrinogen, elevated INR, RVT, and bruising on the abdomen with minimal trauma. The differential diagnosis included infections due to group B Streptococcus, meningococcemia, angioinvasive fungi, ecthyma gangrenosum, and necrotizing fasciitis. (1) Hematologic etiologies included protein C (PC) and protein S (PS) deficiencies (collectively termed “neonatal purpura fulminans” [NPF]), antiphospholipid antibody syndrome, disseminated intravascular coagulation (DIC), cryoglobulinemia and vasculitis (antineutrophil cytoplasmic antibody associated and polyarteritis nodosa). (1)(2)The initial differential diagnosis included sepsis with DIC. Given the localization to the abdomen in an area with recent RVT, the second potential etiologic factor was extension of clotting or embolization of the clot into the vasculature supplying the skin overlying the lower abdomen with subsequent infarction. Abdominal ultrasonography showed stable nonocclusive RVT, bladder wall thickening with intraluminal clot, and scattered hepatic calcifications. Vesicles seen in the skin lesions were presumed to be due to edema. However, they were lanced and a fluid specimen obtained for viral and bacterial culture. Additional sepsis evaluation was initiated and the infant was started on broad-spectrum antibiotics with vancomycin and meropenem. After surgical consultation, the infant was transported to the operating room for emergent exploration and biopsy of skin lesion due to the concern for necrotizing fasciitis. Operative findings described underlying fascia as viable and pink. Fresh frozen biopsy sample was reviewed with the pathologist during surgery and showed thrombi through many of the vessels, but lack of a large polymorphonuclear infiltrate, purulence, or grossly seen bacteria. Wound culture was positive for Staphylococcus epidermidis (in broth only). Complete pathology report revealed thrombotic purpura with focal epidermal necrosis and thrombi being composed primarily of dense aggregates of platelets within fibrin, compatible with NPF.Consistent with the histologic findings and her clinical and laboratory findings of coagulopathy, the infant’s PC activity was significantly low (17%) on chromogenic testing. She was diagnosed with NPF, more specifically type 1 PC deficiency. Initially there was concern for balancing the risk and benefits of anticoagulation given parenchymal brain hemorrhages and the pending diagnostic testing for PC deficiency. Genetic testing via next-generation sequencing detected 2 pathologic variants (c.199G>A [p.Glu67Lys] and c.1166G>C [p.Gly389Ala]) in the PROC gene suggestive of compound heterozygous PC deficiency. Parental PC testing found that her father had a borderline low PC level of 60%, suggesting a possible heterozygous PC deficiency.NPF is a rare autosomal recessive and potentially life-threatening condition that may present in the early neonatal period, with PC deficiency being more common than PS deficiency. Mild PC deficiency affects approximately 1 in 500 individuals (3); severe PC deficiency is rare and occurs in an estimated 1 in 4 million newborns. (3) The lower limit of a normal PC level in healthy infants is 25%, (4) but PC levels do not reach normal adult ranges until after puberty. (5) PC (and PS) will also decrease in the setting of acute thrombosis, making levels challenging to interpret at times. Severe PC deficiency is typically associated with PC levels of less than 1% but NPF can be seen with levels less than 20% (4) in the setting of compound heterozygous mutations or type 2 (functional) mutations. (6) Hereditary PC deficiency is an autosomal recessive disorder, caused by a mutation in the PC (PROC) gene located in chromosome 2q14.3. PC is synthesized in the hepatocytes and circulates as a preprotein in low concentrations in the bloodstream. Once PC is activated at the surface of the endothelial cells, it acts as an anticoagulant and an indirect fibrinolytic agent, as described in Fig 2.NPF is a highly prothrombotic state, so early extensive bruising and/or thromboses should raise awareness for this condition. Initial therapy includes anticoagulation (heparin or enoxaparin), potentially fresh frozen plasma (FFP) if suspicion is high, and then once a diagnosis is made, more directed therapy can be included. Long-term treatments include lifelong PC concentrate or FFP as well as long-term anticoagulation. (4)(7)(8) Curative therapy requires liver transplantation. (6)(9)In this case, PC concentrate 25 U/kg was given daily for 4 days, then weaned to an “as needed” basis. PC concentrate replacement was transitioned to FFP infusions on day 44 after birth, as a more accessible long-term treatment option. The patient transitioned off intravenous heparin to enoxaparin sodium on day 58. Coagulation laboratory findings were very closely monitored while receiving daily FFP infusions. No exacerbations of the previous thrombotic and hemorrhagic complications developed and no further hematologic complications occurred during the NICU stay. FFP infusions were then reduced to every 2 days; however, the D-dimer notably rose before the next FFP infusion. Prothrombin fragment (10) was used as a more specific marker for a prothrombotic state, and it continued to remain elevated. The FFP dose required an increase from 10 mL/kg to 15 mL/kg on day 60. She was then safely transitioned to twice-weekly infusions without significant increases in D-dimer or prothrombin fragment. A central venous catheter was placed by pediatric surgery for ongoing infusions, and the infant was discharged from the NICU at age 2.5 months. Her PC levels stabilized near 30% by 5 months of age without further thrombotic events. FFP was discontinued and the central venous catheter was removed at 6 months of age. She continued to receive scheduled enoxaparin.PC deficiency causes a hypercoagulable state due to a predisposition to reduce thrombin generation resulting from inactivation of factors Va and VIIIa. (2).NPF is a rare, potentially life-threatening condition caused by acquired or congenital severe deficiency of PC or PS. The hallmark of NPF is dermal microvascular thrombosis. (1).DIC secondary to infection is a likely cause of acquired PC deficiency in the neonatal population. (1)(2) Once infectious causes are ruled out, a high index of suspicion is needed for a prompt diagnosis and treatment of congenital PC deficiency. (2)(11).Hereditary PC deficiency is caused by a mutation in the PROC gene. Heterozygous and acquired deficiencies are more common than homozygous deficiency. The recommended laboratory test is the PC chromogenic activity assay. (2)(12).It can be challenging to interpret PC levels in infants and genetic testing takes time. Therefore, if there is strong clinical suspicion for PC deficiency, treatment should be initiated urgently.After the neonatal period, individuals who survive may experience recurrent episodes of purpura fulminans. (12) These patients should be treated with intravenous PC concentrates. (4).

A 5-year old girl with liver transplant was scheduled for a therapy including high-dose cytarabine for her Burkitt lymphoma. Cytarabine pharmacogenetics focus on cytidine deaminase (CDA) , the polymorphic liver enzyme responsible for its detoxification. Preliminary double testing for her CDA status on DNA lymphocytes showed none of the germline polymorphisms usually associated with CDA deficiency (ie, 79A&amp;gt;C (K27Q), 208G&amp;gt;A), but surprisingly with a functional mild deficiency syndrom. Despite 30% reduction in cytarabine dosing, life-threatening toxicities showed quickly and treatment was discontinued. Genetic HRM-based investigations performed in the patient on liver biopsy failed in generating a clear genotype. Further HRM+sequencing retrospective investigations on liver biopsy collected from the donor showed that he was actually bearing the homozygous CDA*2 allelic variant (ie, 79AA), a genotype usually associated with severe CDA deficiency. Based upon the donor liver genotype, and not the recipient genotype, treatement was resumed with further dose reduction, close monitoring and better tolerance eventually. The patient is now in complete remission more than a year after completion of the treatment. This case report illustrates the limits and risks of searching germline polymorphisms in patients with liver transplant when the story plays in the liver. Citation Format: Cindy Serdjebi, Raphaelle Fanciullino, Frederic Fina, Arnaud Verschuur, Bertrand Roquelaure, Bruno Lacarelle, L'Houcine Ouafik, Joseph Ciccolini, Nicolas André. Recipient-donor contradictory genotype with impact on anticancer drug pharmacogenetics after liver transplant: A deadly gift. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 5549. doi:10.1158/1538-7445.AM2014-5549

From futility to promise: Preemptive veno-arterial extracorporeal membrane oxygenation benefits high-risk liver transplant patients.

Transfusion MedicineVolume 24, Issue 4 p. 251-253 LETTER TO THE EDITOR Successful liver and lung transplantation in patients with severe IgA deficiency, high anti-IgA concentration and a history of anaphylactic transfusion reaction S. Bäckman, Corresponding Author S. Bäckman Finnish Red Cross Blood Service, Helsinki, Finland Correspondence: Sari Bäckman, Finnish Red Cross Blood Service, Kivihaantie 7, 00310 Helsinki, Finland. Tel.: +358 405958420; fax: +358 293001604; e-mail: [email protected]Search for more papers by this authorK. Javela, K. Javela Finnish Red Cross Blood Service, Helsinki, FinlandSearch for more papers by this authorA.-M. Koivusalo, A.-M. Koivusalo Meilahti Hospital Intensive Care Unit 20, Helsinki, FinlandSearch for more papers by this authorH. Isoniemi, H. Isoniemi Transplantation and Liver Surgery Clinic, Helsinki, FinlandSearch for more papers by this authorM. Halme, M. Halme Helsinki Heart and Lung Centre, Helsinki University Central Hospital, Helsinki, FinlandSearch for more papers by this authorP. Hämmäinen, P. Hämmäinen Helsinki Heart and Lung Centre, Helsinki University Central Hospital, Helsinki, FinlandSearch for more papers by this authorS. Koskinen, S. Koskinen Finnish Red Cross Blood Service, Helsinki, FinlandSearch for more papers by this author S. Bäckman, Corresponding Author S. Bäckman Finnish Red Cross Blood Service, Helsinki, Finland Correspondence: Sari Bäckman, Finnish Red Cross Blood Service, Kivihaantie 7, 00310 Helsinki, Finland. Tel.: +358 405958420; fax: +358 293001604; e-mail: [email protected]Search for more papers by this authorK. Javela, K. Javela Finnish Red Cross Blood Service, Helsinki, FinlandSearch for more papers by this authorA.-M. Koivusalo, A.-M. Koivusalo Meilahti Hospital Intensive Care Unit 20, Helsinki, FinlandSearch for more papers by this authorH. Isoniemi, H. Isoniemi Transplantation and Liver Surgery Clinic, Helsinki, FinlandSearch for more papers by this authorM. Halme, M. Halme Helsinki Heart and Lung Centre, Helsinki University Central Hospital, Helsinki, FinlandSearch for more papers by this authorP. Hämmäinen, P. Hämmäinen Helsinki Heart and Lung Centre, Helsinki University Central Hospital, Helsinki, FinlandSearch for more papers by this authorS. Koskinen, S. Koskinen Finnish Red Cross Blood Service, Helsinki, FinlandSearch for more papers by this author First published: 28 July 2014 https://doi.org/10.1111/tme.12136Citations: 7Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume24, Issue4August 2014Pages 251-253 RelatedInformation

We demonstrate the effective use of NMR spectroscopic profiles of urine and plasma from the first successful use of hepatocyte transplantation as a bridge to auxiliary partial orthotopic liver transplantation in a child antenatally diagnosed with severe ornithine transcarbamylase deficiency. In this single-patient study, NMR profiles indicated that the disrupted urea cycle could be normalized by hepatocyte cell infusion and this was confirmed using orthogonal partial least-squares-based chemometrics. However, despite dietary manipulations and adminstration of ammonia scavengers, the desired reduction in plasma ammonia was not consistently achieved between sessions of hepatocyte transplantation due to episodes of sepsis. A subsequent liver transplant corrected the metabolic abnormalities. The use of metabolic profiling has been shown to be a promising method for evaluating the efficacy of cell infusions and has demonstrated the capability for the early detection of response to therapy in real time, an approach that may be of use in wider clinical settings.

Potential conflict of interest: Dr. Thompson is employed by, owns stock in, is on the speakers' bureau of, and received grants from Shire. This work was partially supported by a grant to S.E.P. (NHGRI/NCI U01HG006485). Mutations in TJP2 (also named ZO‐2), encoding tight‐junction protein 2 (TJP2), cause an autosomal‐recessive form of progressive intrahepatic cholestasis.1 Association of TJP2 deficiency with hepatocellular carcinoma (HCC) in childhood has not been recognized. Case Reports Patient 1 A 26‐month‐old Caucasian female with intermittent jaundice of neonatal onset and unknown etiology, with normal‐range serum gamma‐glutamyltransferase (GGT) activity, presented with liver failure. Computed tomography revealed innumerable well‐defined hepatic masses. Serum alpha‐fetoprotein (AFP) level was high (171,000 ng/mL). Liver biopsy (Fig. 1A‐E) found moderately differentiated HCC (expressing glypican‐3, p53, and AFP) in a background of chronic cholestatic hepatitis with cirrhosis. Mutational analysis detected no significant variants in ABCB11. Both bile salt export pump (BSEP) and multidrug resistance protein 3 (Fig. 1F,G) were well expressed. Because these features may result from TJP2 deficiency, TJP2 was sequenced.1 Compound heterozygous mutations were found, with c.2668‐1G>T /c.2438dupT (p.Asn814Glnfs) (NM_004817.3). TJP2 expression was not immunohistochemically demonstrable, and claudin‐1 expression was markedly decreased (Fig. 1H,I), supporting the diagnosis of TJP2 deficiency. The patient died 3 weeks after admission. Autopsy confirmed multifocal HCC (0.5‐4.0 cm in the greatest dimension).Figure 1: Patient 1. Non‐neoplastic liver shows micronodular cirrhosis (A) and prominent rosetting with bile plugs in canalicular lumina (B). (C and D) Low‐ and high‐magnification views of HCC. Tumor cells show variable cytoplasmic clearing and round to oval, sometimes pleomorphic nuclei with variably sized nucleoli. Some cells contain distinct round to oval eosinophilic cytoplasmic proteinaceous inclusions (arrow in D). Macrosteatosis and mitosis (arrow in E) are also present. BSEP (F) and multiple drug resistance protein 3 (G) are well expressed in non‐neoplastic liver. (H) Complete absence of TJP2 staining in bile ducts. (I) Markedly decreased claudin‐1 staining in both cholangiocytes and canalicular margins. Control liver shows normal TJP2 expression in bile duct (inset in H) and strong claudin‐1 expression in both bile ducts and canaliculi (inset in I). (A) Trichrome stain. (B‐F) Hematoxylin‐eosin stain. Original magnification: ×40 for (A); ×100 for (C); ×200 for (B), (D), and (E); and ×400 for (F)‐(I).Patient 2 A 6‐month‐old Caucasian male was referred for persistent cholestasis with near‐normal GGT after hepatoportoenterostomy for presumed biliary atresia. His parents denied consanguinity. No etiology was defined; workup included Sanger sequencing of ABCB11. Liver biopsy found cholestatic hepatitis (Fig. 2A). Icterus resolved by age 19 months, but a growing lesion in the right liver lobe, with rising serum AFP, prompted liver transplantation (LT) at age 2 years. The explanted liver was cirrhotic, with multiple cholestatic nodules and a single, well‐encapsulated 2‐cm tumor that diffusely expressed AFP and glypican‐3; a central region of well‐differentiated HCC was found (Fig. 2B‐D). Blood and tumor whole‐exome sequencing found homozygosity for c.817delG (p.A273fs) in TJP2, predicted to cause a frameshift in all transcripts of TJP2. Sanger sequencing validated the mutation, for which each parent was heterozygous. TJP2 expression was absent (Fig. 2E), and claudin‐1 expression was markedly decreased in nontumoral liver. The patient is well 2 years post‐transplantation.Figure 2: Patient 2. (A) Liver biopsy at 6 months displays severe cholestasis, giant cell transformation, and micronodular cirrhosis. (B) Macroscopic photograph of the explant reveals multiple cholestatic nodules and one much larger and softer tan nodule with focal bile pigmentation (arrow), within which HCC was found histologically. (C) Within the large, soft nodule, a sharply delineated smaller aggregate of highly pleomorphic, mitotically active cells (arrows) is typical of HCC. (D) Glypican‐3 expression (brown staining) is observed in HCC and regenerative nodule, but not in non‐neoplastic hepatocytes (left upper). (E) TJP2 is not expressed at bile canaliculi of the patient's liver biopsy specimen, whereas it is observed anomalously in hepatocyte nuclei. Control liver shows normal canalicular expression of TJP2 (inset). (A and C) Hematoxylin‐eosin stain. Original magnification: ×125 for (D) and ×200 for (A), (C), and (E).Discussion Both patients had clinical and histological features similar to those of BSEP deficiency, which predisposes to HCC in childhood.2 However, neither ABCB11 mutation nor BSEP deficiency was demonstrable. Instead, biallelic TJP2 truncating mutations were found in both cases. TJP2 expression at cholangiocyte apices and bile canaliculus margins was entirely absent. As with Sambrotta et al.,1 we found deficiency of canalicular claudin‐1 expression. Therefore, we ascribe liver disease in both patients to severe TJP2 deficiency.​ We infer that TJP2 deficiency predisposes to HCC development in early childhood. How it does so is unclear. Though many toddlers have severe cholestatic liver disease, very few develop HCC. This makes an indirect and nonspecific effect of TJP2 deficiency unlikely. Down‐regulation of TJP2 function in various tumor types3 may suggest direct tumorigenesis. However, such down‐regulation is perhaps secondary and nonspecific. HCC in children with BSEP deficiency may arise by several routes. A case in which mutations such as those found in adult HCC underlay tumorigenesis is reported,4 as are several cases in which massive gene amplification was found.5 These mechanisms remain to be assessed in pediatric HCC with backgrounds of other cholestatic disorders, including TJP2 deficiency. TJP2 mutation must be considered in patients with intrahepatic cholestasis and normal‐range GGT. TJP2 deficiency may predispose to HCC in early childhood, warranting close monitoring and early LT.

Biliary atresia, severe FIC1 and severe BSEP deficiency (also known as PFIC1 and PFIC2) are rare cholestatic childhood diseases. The aim of this thesis was to identify novel targets of intervention for improving the prognosis of patients suffering these diseases. The studies conducted in this thesis demonstrate that national or global collaboration allows to obtain novel insights in the natural history of rare liver diseases and their responsiveness to specific treatments. These insights have already led to patient-tailored changes in treatments for these diseases and are expected to have more impact in the near future, not only for the care and counselling of individual patients but also for understanding the pathophysiology of these rare diseases. The studies underline the value, if not the necessity, of collaborative efforts of clinicians, authorities and patient advocates for improving the prognosis of patients with rare diseases and for the advancement of science.

AIMTo investigate the relationship between 25-hydroxyvitamin D (25-OHD) deficiency and hepatic encephalopathy (HE) in patients with chronic liver disease (CLD).METHODSA retrospective analysis of the results of 392 adult patients with chronic liver disease who were assessed for liver transplantation between 2006 and 2010 was undertaken. HE, severity of CLD, nutritional status and 25-OHD were analysed in patients assessed for liver transplantation between 2006 and 2010. Patients who presented with acute, fulminant or subacute disease, with a primary diagnosis of liver cancer, were assessed for re-transplantation or who did not have a 25-OHD measurement were excluded from the analysis.RESULTSOne hundred and sixty-five patients were included in this analysis. The mean age of all patients was 53 ± 8 years. Moderate to severe 25-OHD deficiency was identified in 49 patients of whom 36 had grade 2-3 HE compared with 13 patients who were not encephalopathic (P ≤ 0.0001). Mild 25-OHD deficiency was not associated with HE. There was a significant correlation between the severity of 25-OHD deficiency and the severity of liver disease (r = 0.39, P ≤ 0.0001) and disease severity and the presence of HE (P ≤ 0.0001). Importantly, individuals with 25-OHD deficiency were more likely to have a diagnosis of overt HE (OHE) at a significantly lower model for end stage liver disease (MELD) score than individuals without OHE (P ≤ 0.0001). This significant difference was observed with MELD scores from 10 to 38.CONCLUSION25-OHD deficiency was observed in the majority of patients with CLD and for the first time was found to be significantly worse in patients with OHE.

Successful Liver Transplantation for a Child With Life-Threatening Recurrent Bleeding Episodes Due to Congenital Factor X Deficiency: A Case Report

Lipoprotein metabolism in FIC1 deficiency due to ATP8B1 mutations has never been studied sufficiently. This study was performed to investigate the detailed lipoprotein metabolism in benign recurrent intrahepatic cholestasis (BRIC) caused by FIC1 deficiency. Lipoprotein profile and major lipoprotein regulators such as lecithin:cholesterol acyltransferase (LCAT), hepatic triglyceride lipase (HTGL), lipoprotein lipase, and cholesteryl ester transfer protein in a Japanese patient with BRIC were serially examined during a bout of cholestasis. Liver expression of farnesoid X receptor (FXR), which suppresses high-density lipoprotein (HDL) generation, was also examined. Hypercholesterolemia and lipoprotein X accumulation were never observed throughout this study. When the cholestasis was severe, triglyceride-rich low-density lipoprotein (LDL) accounted for most of the plasma lipoproteins whereas HDL was hardly detectable. Concurrently, activities of all regulators were decreased, together with decreases of the serum parameter for liver protein synthesis. In particular, suppressions of LCAT and HTGL activities were severe and greatly contributed to the appearance of triglyceride-rich LDL. As the cholestasis improved, this LDL gradually transformed into normal LDL with the recoveries of LCAT and HTGL activities. The activities of all regulators for the last 1 to 2 months were normal but HDL remained depleted. His liver showed low FXR expression compared with control livers. The present study showed an appearance of triglyceride-rich LDL due to suppressions of LCAT and HTGL activities and a depletion of HDL that is not able to be explained by lipoprotein regulators or FXR in our patient.