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胆盐代谢及转运和肝内胆汁淤积 —— 分子医学和临床的相互促进

胆盐代谢及转运和肝内胆汁淤积 —— 分子医学和临床的相互促进. 王建设 复旦大学附属儿科医院 复旦大学儿童肝病中心. “ 特发性 ” 新生儿肝炎. GGT and the outcome July 1, 1981-Jan 1, 1985, 186 infants, 29 diagnosed as INHS, followed up for at least 1 year, or until death: 17 with increased GGT (>=2.1*normal upper limit), All but 1 in good prognosis

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胆盐代谢及转运和肝内胆汁淤积 —— 分子医学和临床的相互促进

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  1. 胆盐代谢及转运和肝内胆汁淤积——分子医学和临床的相互促进胆盐代谢及转运和肝内胆汁淤积——分子医学和临床的相互促进 王建设 复旦大学附属儿科医院 复旦大学儿童肝病中心

  2. “特发性”新生儿肝炎 • GGT and the outcome July 1, 1981-Jan 1, 1985, 186 infants, 29 diagnosed as INHS, followed up for at least 1 year, or until death: • 17 with increased GGT (>=2.1*normal upper limit), All but 1 in good prognosis • 12 with normal GGT, All poor prognosis Maggiore G, et al. J Pediatr, 1987;112:251-252.

  3. King’s病例入选标准 • Aug 1991 to Nov 2000, Conjugated hyperbilirubinemia under 3 months of age (973 cases) • No specific etiologic factor can be ascertained after comprehensive work-up • Followed up for at least one year or until died

  4. Wang JS, Eur J Pediatr, 2006, in press

  5. 病例排除标准 • INR>1.2 and not be fully corrected after vitamin K injection • Follow up interval longer than 3 months • Other severe congenital abnormalities • G6PD deficiency • Evidence of active CMV infection in spite of no inclusion found on liver biopsy • USS demonstrated bile duct dilation.

  6. Basic information • 128 cases elected, 110 biopsyed • 6 patients diagnosed as PFIC 1 or 2, 1 recurred jaundice. GGT level with endpoints without endpoints Presentation 29-84 52.9%<100 Peak 36-93 13.2%<100

  7. The basic and biochemistry characteristics with endpoint without endpoint Birth weight (g) 3353.3394.93 2410.3589.64* Age of jaundice noticed 29.508.59 13.491.28* Biochemistry at first presentation TB (mmol/l) 183.3328.14 159.649.03 DB (mmol/l) 132.1718.81 119.178.29 AST (U/L) 376.33113.92 196.8019.77 GGT (U/L) 45.838.21 165.8214.30* Peak biochemistry at the first three months of follow up TB (mmol/l) 26474.06 167.288.54 AST (U/L) 569.57180.4 238.2224.23* GGT (U/L) 58.717.43 311.7120.68*

  8. PFIC

  9. ekyy入选标准 • 2001年6月～2004年5月就诊于传染科 • 诊断为婴儿肝炎综合征 • 同时符合以下指标 • 血清总胆红素（TB）≥85umol/L • 血清结合胆红素(CB)占总胆红素≥15％ • 腹部B超、同位素肝胆显像、遗传代谢病筛查等除外先天性胆道闭锁、胆道扩张及其他先天性异常(CMV指标阳性，但无多系统受累的不除外) • 专科门诊随访至黄疸消退、死亡或一年以上

  10. 结果 • 最终有38例患者符合以上条件 • 入院时的γ－GT按50U/L进行分组 • ≤50U/L组6例，5例预后不良 • >50U/L组32例，3例预后不良(P=0.001) • 峰值γ－GT 100U/L进行分组 • ≤100U/L组10例，6例预后不良 • >100U/L组28例，2例预后不良(P=0.002) • 血清GGT水平和预后的有关（和CMV状态无关） 王中林. 肝脏 2005，(4)

  11. 进行性家族性肝内郁胆（PFIC） • First reported in Amish family (Byler disease), autosomal recessive inheritance • Clinical presentation: • Cholestasis and low GGT • Pruritus, Epistaxis • Normal or near normal cholesterol, No xanthomas

  12. FIC1 deficiency • BRIC 基因定位18q21-22 • Houwen RH, 1994, Nat Genet 8:380 • PFIC (Byler disease)基因定位18q21-22 • Carlton VE, 1995, 4:1049-1053 • PFIC遗传异质性，PFIC1 • ATP8B1基因，编码的产物FIC1 • Bull LN, Nat Genet 1998, 18:219

  13. FIC1 deficiency (续) • Greenland familial cholestasis, Asp554Asn • Klomp LW, Hepatology, 2000,32:1337 • 各地的散发性病例 • 无家族史、父母非近亲婚配 • 欧洲、日本、中国台湾 • 新认识 • PFIC1和BRIC 1有同一基因引起 • PFIC多见缺失、移位、无义突变 • BRIC多见错义突变 • PFIC1和BRIC 1可表现为一连续过程 • 共同的临床特征

  14. Low GGT in cholestasis • Low GGT expression • Defect of bile salt exportation

  15. BSEP deficiency • 1997年，低GGT PFIC的第二个基因（沙特）被定位于2q24，因此这种被命名为PFIC2 • Strautnieks SS. Am J Hum Genet. 61,630. • 1998年， BSEP基因突变引起PFIC 2 • Strautnieks SS. Nat Genet. 20,233. • 2004 年，BRIC 2由ABCB11突变 • PFIC多见缺失、移位、无义突变, BRIC多见错义突变 • van Mil SWC, Gastroenterology, 127,379. • PFIC 2 见于欧洲、日本、 中国等世界各地

  16. Case 2 20061388 G>A, A167I

  17. Case 3 CAG TAGExon 18 C2230T Q702Stop

  18. Case 5 Intron 22 (+3) Exon 7 T A 562 G>T G188W

  19. Case 5 • Intron 22 (+3) • 紧邻剪切位点(ACCT) T to A • Hum AAGATTACCTG • Mus AAGATTACCTG • Dog AAGATTACCTG • CowTAGATTACCTG • CaseAAGATAACCTG

  20. Case 7 • Intron 6 • T+63T/G • (167)

  21. Low GGT in cholestasis • Defect of bile salt exportation • Defect of bile salt synthesis

  22. Bile acid synthetic defect • 16 enzymes catalyze 17 reactions in bile acid synthesis from cholesterol Russell DW. Annu Rev Biochem 2003,72,137 • Defects in different enzymes associate with neonatal cholestasis • Delta(4)-3-oxosteroid 5beta-reductase(AKR1D1) Gonzales E, J Hepatol 2004,40,716 • Oxysterol 7-hydroxylase (CRP7B1) Setchell KDR, J Clin Invest 1998,102,1690

  23. Bile acid synthetic defect -PFIC 4 • 2000, HSD3B7, chromosome 16p12-p11.2 • Encoding 3-beta-hydroxy-delta-5-C27 steroid oxidoreductase (C27-3-BETA-HSD) • Participate in all pathways of bile acid synthesis (7-alpha-hydroxylated sterols) • 2 bp deletion in a Saudi boy with neonatal PIC Schwarz M. J Clin Invest 2000,106,1175 • 2003, confirmed in a Chilean family, a French family, a British and a Canadian family Cheng JB. J Clin Endocr Metab 2003, 88:1833

  24. 对临床的意义 • 将PFIC和BRIC区分出不同的类型 • Diarrhea, Pancreatitis （PFIC1) • 胆石症 （PFIC2) • 将PFIC和BRIC有机的联系在一起 • 疾病的两极，表型可转换 • van Ooteghem NA, J Hepatol 2002,36,439 • 预后判断 • More progressive in BSEP • Malignancy in BSEP • Growth retardation in FIC1

  25. 对临床的意义 • Histology • PFIC1：Cholestasis with nonspecific hepatitis, Low expression of GGT at canalicular • PFIC2：Neonatal hepatitis （multinuclear giant cell transformation) • Bile acid synthetic defect: Giant cell hepatitis Chen HL, J Pediatr. 2002,140,119 Knisely AS. Perspect Pediatr Pathol 2000,3,113 Bove KE. Pediatr Dev Pathol 2004,7,315

  26. 对临床的意义 • Treatment • Exogenous bile acid administration • Cure for some bile acid synthetic defect • Transplatation • cure the disease in BSEP • Outside liver symptoms continue(FIC1) • Partial bile diversion • D482G or E297G respond well in BSEP

  27. “Transit”neonatal hepatitis • The remaining 103 infants were included for analysis. Median age at presentation was 40 days (range 7 - 87 days) • Follow up period ranged between 315 days to 9.6 years, with a median of 873 days • There were no patient deaths

  28. 根据入院时GGT分组，组织学表现有区别

  29. Wang JS, Eur J Pediatr, 2006, in press

  30. Typical biochemistry dynamic profile in “transit”patients GGT levels rise as bilirubin & AST levels fall. There is a wide variation in time intervals to peak and resolution of disease. This patient presented on day 10 and disease resolved by day 151.

  31. Biochemistry dynamic profile of patient presenting early presented on day 3 with a GGT 387 IU/L and CB 83µmol/L GGT fell to 71 IU/L on day 46 as the AST levels rose A second peak of GGT on day 169 as the bilirubin & AST levels fell.

  32. Children with idiopathic neonatal hepatitis have more severe disease if their presenting GGT levels are ≤ 100 IU/L However, the outcome appears to be good if the GGT becomes raised at a later point of disease Further research is required to elucidate the cause of low GGT levels and establish the possible etiologies of idiopathic neonatal hepatitis. BSEP gene deletion in a “transit” neonatal hepatitis

  33. 病初曾有血清TB下降而GGT升高达400U/L 黄疸加重而GGT下降至50U/L左右，TB和ALT持续波动，而GGT始终不高，最终于1岁前死于肝功能衰竭

  34. 结 论 • 郁胆伴持续低GGT是PFIC的重要特征 • 入院时GGT水平和疾病严重程度有关 • 预后良好的特发性新生儿肝炎具有典型的血清GGT动力学 • 淤胆加重而GGT水平下降可能是毛细胆管水平胆盐分泌和排泄衰竭的表现 • 机制的阐明分子医学的深入研究

  35. THANK YOU

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