Deciphering the causes of

neonatal cholestasis

Jorge A. Bezerra, M.D.

Division of Pediatric GI,
Hepatology, & Nutrition

Clinical Problem - 1
Full term infant; no complications
Jaundice at day 2; resolution by day 9
At 2 months of age
Breastfeeding
Well-infant visit:

Good weight gain; jaundice; decreased appetite

AST: 124 IU/L
AST: 157 IU/L
Albumin: 3.5 g/dL
Conjugated bilirubin: 3.8 mg/dL
APh: 420 GTP: 587 IU/L

What is the diagnosis?

Clinical Problem - 2
3.5 yr old boy with jaundice and pruritus
Ht/Wt ~50th%ile
AST: 167 IU/L
AST: 142 IU/
Albumin: 3.6 g/dL
Conjugated bilirubin: 2.6 mg/dL
Serum bile acids: 56; GTP: 22 IU/L

No hepatomegaly; spleen 3 cm LCM

Jaundice in the first 2 months of age
No history of diarrhea
What is the diagnosis?

Clinical Problem - 3
6 month old boy with:
Arthrogryposis multiplex congenita
Jaundice
Conjugated bili: 4.3 mg/dL; GTP: 32 IU/L
Normal synthetic function

Renal dysfunction
Renal Fanconi syndrome
Nephrocalcinosis

Liver histology
Giant cell transformation; ductopenia

What is the diagnosis?

Mutation in the VPS33B gene

Cholestasis as a sign/symptom
Neonatal
cholestasis

Childhood
cholestasis

Non-hepatic
syndrome

Cholestasis

Cholestasis

Pigment of my imagination?
PHYSIOLOGIC
Abnormal decrease in biliary flow

HISTOPATHOLOGIC
Histological evidence of bile within
canaliculi or bile ducts

CLINICAL
Accumulation of substances normally
excreted by bile in plasma and extrahepatic
systems

The hepatic excretory system

Bile

Unconj. Bili
Aminoacids
Organic anions
Others

Conj. bilirubin
Bile acids
Lipids (cholesterol)
Proteins
Lytes, Vitamins...

Cholestasis and sites of injury

Bile

Unconj. Bili
Aminoacids
Organic anions
Others

Conj. bilirubin
Bile acids
Lipids (cholesterol)
Proteins
Lytes, Vitamins...

Intrahepatic cholestasis
12 months
JAUNDICE
COAGULOPATHY
XANTHOMA (?)
RICKETTS (?)

>12 months

JAUNDICE
COAGULOPATHY
XANTHOMA
RICKETTS
NEURO DEFICITS
PRURITUS

Temporal dynamics of jaundice

3 wk of age, breastfed
growing well (5-10th%ile), jaundiced

Bilirubin

U.B.

U.B.

2 wk

C.B.

4 wk

Evolving spectrum of cholestasis

<1970
-INFECTION
-IDIOPATHIC
-ATRESIA

1970-2000
-INFECTION
-ATRESIA
-A1AT def (met)
-ALAGILLE
-PFIC
-IDIOPATHIC

Clinical Problem - 1
Full term infant; no complications
Jaundice at day 2; resolution by day 9
At 2 months of age
Breastfeeding
Well-infant visit:

Good weight gain; jaundice; decreased appetite

AST: 124 IU/L
AST: 157 IU/L
Albumin: 3.5 g/dL
Conjugated bilirubin: 3.8 mg/dL
APh: 420 GTP: 587 IU/L

What is the diagnosis? A1AT PiZZ

A1AT Deficiency

Infant with cholestasis

11 month old male infant
History of transient neonatal jaundice
Exam
Typical facial features, posterior embryotoxon
Cardiac murmur, vertebral body abnormalities

Laboratory studies:

AST: 111 IU/L

AST: 108 IU/L
Albumin: 3.7 g/dL
Conjugated bilirubin: 2.9 mg/dL
APh: 201 GTP: 387 IU/L
Cholesterol: 785

The Alagille Disease

The Alagille Disease

SIGNAL PEPTIDE

EGF-like
repeats

CYSTEINE
TRANSMEMBRANE

INTRACELLULAR
DOMAIN

JAG1 protein

The Alagille Disease

Main Criteria

Interlobular bile ducts

Extrahepatic involvement:
Facial features
Vertebral body abnormalities
Cardiovascular defects
Posterior embryotoxon
Renal abnormalities

91%
95%
87%
70%
89%
68%

The Alagille Disease

Minor Criteria

Poor growth
Inadequate development
Hypogonadism
Bone disease
High-pitched voice
Abnormal vasculature in
central nervous system

50%
60%
<10%
<10%
<10%
?

The hepatic excretory system

Bile

JAG1

Evolving spectrum of cholestasis

<1970
-INFECTION
-IDIOPATHIC
-ATRESIA

1970-2000
-INFECTION
-ATRESIA
-METABOLIC
-ALAGILLE
-PFIC
-IDIOPATHIC

2000...
-INFECTION
-ATRESIA
-METABOLIC
-ALAGILLE
-FIC1 DEFECT (PFIC1)
-FIC1 DEFECT (GREENLAND)
-FIC1 DEFECT (BRIC)
-FIC1 DEFECT (FAROE IS.)
-BSEP DEFICIENCY (PFIC2)
-MDR3 DEFICIENCY (PFIC3)
-3HSD DEFICIENCY
-IDIOPATHIC (VARIANTS ?)

ABC Transporters
A lesson in family values
FIC1

MDR3

BSEP

MRP2

United to promote biliary flow

PFIC syndromes
MRP2 (Conj. bili)

FIC1 (P-ilserine)

Bile

Mutant 3HSD

BSEP (Bile salts)

MDR3 (phospholipids)

FIC1?

PFIC syndromes
Familial cholestasis
Progression to end-stage liver disease
Clinical features
Cholestasis: recurrent or persistent
Autosomal recessive pattern
Variable levels of aminotransferases
Subgroup with low levels of GTP
Typical histologic/EM findings

Exclusion of known causes of chronic

cholestasis

Neonatal cholestasis

NEONATAL
CHOLESTASIS
Use of LFTs in
to identify PFIC
INFECTION

BILIARY ATRESIA

METABOLIC DISEASE

IDIOPATHIC

GTP

AST/ALT: Elevated
Conjugated bili: Elevated
GTP: ()
Alk Phosph: Elevated
Elevated bile acids ()
Elevated cholesterol ()

FIC1 defect

Bylers disease

Onset of cholestasis in the 1st yr of life

Recurrent cholestasis
cirrhosis
Pruritus
Diarrhea, pancreatitis, hearing defect
Gamma-GTP: Normal or low
Histology
Canalicular cholestasis, mild ductular
changes or inflammation, granular bile (ME)

Often require OLT before 10 years

Molecular defect
Translocation of Ph-tidylserine and Phethanolamine from inner to outer leaflet

EM: Granular bile

FIC1 defect

BRIC & Cholestasis in Faraoe Is.

Recurrent cholestasis
No progression to cirrhosis
Cycles: Jaundice, pruritus, weight
loss, steatorrhea
Gamma-GTP: Normal or low
Histology: Normal or minimal changes
Require treatment for pruritus

FIC1 defect

Greenland familial cholestasis

Progressive cholestasis
Pruritus, steatorrhea, poor growth
Gamma-GTP: Normal or low
Histology:
Fibrosis, granular bile (ME)

Mortality: 50% at 3 years

BSEP deficiency
Clinical features similar to Bylers
Recurrent cholestasis, pruritus
Progression to chronic liver disease
Gamma-GTP: Normal or low

Lack of extrahepatic manifestations

Genetic mutations in 2q24

Histology
Giant cell hepatitis, inflammation, progression
to fibrosis, canalicular cholestasis

Molecular defect
Export of bile salt into canalicular

BSEP deficiency

BRIC-2
van Mill et al. Gastroenterology
2004;127:379
Clinical features similar to BRIC
Recurrent cholestasis, pruritus
No evidence of disease progression
Gamma-GTP: Normal or low

Histology
No evidence of severe fibrosis

Sequence of BSEP (ABCB11) gene

Mutation
Spectrum of disease of BSEP deficiency

MDR3 deficiency

Clinical features similar to Bylers

Milder symptoms
Progression to chronic liver disease: slow?

High GTP
Histology
Portal inflammation, ductal proliferation
Variable degree of fibrosis

Other diseases
Intrahepatic cholestasis of pregnancy
Cholesterol-rich cholelithiasis

Molecular defect
Impaired export of aminophospholipids

3HSD deficiency
Clinical features similar to Bylers
Deficiency of fat-soluble vitamins
Gamma-GTP: Normal or low
High conjugated bilirubin
Bile acids: Normal/low (cholestasis)
Absence of pruritus

Histology
Portal inflammation, variable fibrosis

Coagulopathy and vitamin deficiency

improve with UDCA

The hepatic transport system

A1AT deficiency

MRP2

Dubin-Johnson
FIC1 defect
BSEP deficiency
MDR3 deficiency

FIC1 defect

FIC1
BSEP
MDR3

Mutant
3HSD

FIC1?

JAG1
Cystic fibrosis

BASD

Cl-

CFTR

Alagille synd.

Evolving spectrum of cholestasis

1970-2000

2000...

2005

Intrahepatic cholestasis
Clinical syndromes

Complex group; different prognosis

Incidence
Individually: rare; as a group: frequent

Challenge: group patients

Clinical features
Syndromic features? Pruritus? Severity?

Biochemical markers
PT/INR; conj (direct) bili; GTP

Liver biopsy
Molecular diagnosis: not routine

Intrahepatic cholestasis
Treatment

Nutritional support
Calories to promote adequate growth
A,D,E,K vitamin supplementation

UDCA: 15-30 mg/kg/day

Pruritus
Add rifampin: increases bile acid excretion

Biliary diversion
External biliary diversion
Internal biliary diversion
May halt progression of liver disease

Liver transplantation

Relationship between cholestasis

and multi-system disease
1970-2000
-INFECTION
-ATRESIA
-A1AT def (met)
-ALAGILLE
-PFIC
-IDIOPATHIC

2000...
-INFECTION
-ATRESIA
-A1AT def (met)
-ALAGILLE
-FIC1 DEFECT (PFIC1)
-FIC1 DEFECT (GREENLAND)
-FIC1 DEFECT (BRIC)
-FIC1 DEFECT (FAROE IS.)
-BSEP DEFICIENCY (PFIC2)
-MDR3 DEFICIENCY (PFIC3)
-3HSD DEFICIENCY
-IDIOPATHIC (VARIANTS ?)

2005
-INFECTION
-ATRESIA
-A1AT def, CF
-ALAGILLE
-FIC1 defect
-BSEP deficiency
-MDR3 deficiency
-3HSD deficiency
-Unclassified
-Cholestasis and
multi-system Dz

Summation
Present as jaundice, pruritus, and/or
complications of deficiency of ADEK
Neonatal onset; pre- or school age
Biochemistry: bilirubin vs GTP
Liver biopsy: cellular organization,
degree of fibrosis, EM
Nutritional support, ADEK
Treatment of pruritus
Medication
Surgery

Liver transplantation

Unclassified syndromes
Lymphedema-cholestasis syndrome or
Aaganaes syndrome
Lymphedema: mostly lower extremities
Episodic intrahepatic cholestasis
Low GTP
Cholesterol levels may be low
Variable progression of liver disease
Autosomal recessive
Two loci may exist (LCS-1 and LCS-2)

Unclassified syndromes
North-American Indian childhood cirrhosis
(NAIC syndrome)
Severe form of intrahepatic cholestasis
Typically presents with mild neonatal
cholestasis, but progresses to biliary cirrhosis
Liver transplantation: only effective treatment
Mutation in Cirhin (CIRH1A)
Mostly expressed in the embryonic liver
The biological relationship between Cirhin and
cholestasis is unknown

Unclassified syndromes
Neonatal intrahepatic cholestasis caused
by citrin deficiency (NICCD syndrome)
Type II cytrulinemia (adult-onset)
Neonatal cholestasis; micro/macro steatosis
Variable degrees of synthetic dysfunction
Vomiting, poor growth, irritability
Mutation in citrin (SLC25A13), 7q21.3 mitochondrial aspartate-glutamate carrier
Markedly elevated plasma citrullin, high
methionine, hypergalactosemia
Supportive care; improvement by 1 yr of age

Relationship between cholestasis

and multi-system disease
Arthrogryposis-renal dysfunctioncholestasis syndrome (ARC syndrome)
Neurogenic arthrogryposis multiplex
congenita
Renal tubular dysfunction: nephrocalcinosis,
renal Falconi syndrome
Neonatal cholestasis, low GTP, duct paucity
Death in the first year of life
Mutation in the VPS33B gene (15q26.1)
Abnormal protein trafficking & memb. fusion

Relationship between cholestasis

and multi-system disease
McCune-Albright syndrome
Polyostotic fibrous dysplasia, caf-au-lait skin
pigmentation
Peripheral precocious puberty in girls
Cholestasis: basis of cholestasis is unknown
Postzygotic activating mutations of arginine 201 in
the G protein-alpha subunit

Niemann-Pick syndrome disease type C

Neonatal cholestasis, disproportionate splenomegaly
Mild developmental delay
Defective cellular cholesterol esterification

The hepatic transport system

K+
MRP2 (Conj. bili)

Na+
NTCP

FIC1 (P-ilserine)

Bile

OATPs

BSEP (Bile salts)

MDR3 (phospholipids)

hOCT1

FIC1?

IBAT

CFTR
AE2

ClClHCO3-

The hepatic transport system

AT-ZZ
MRP2 (Conj. bili)

FIC1 (P-ilserine)

Bile

Mutant 3HSD

BSEP (Bile salts)

MDR3 (phospholipids)

FIC1?

JAG1