Childhood Cirrhosis Research Articles

α1‐antitrypsin deficiency and liver disease: Clinical presentation, diagnosis and treatment

The alpha 1-antitrypsin deficient subject (protease inhibitor (PI) phenotype ZZ) has an increased susceptibility to liver disease. The condition is most commonly identified in early infancy as a conjugated hyperbilirubinaemia with hepatitis (11%) or a bleeding state due to vitamin K malabsorption (2%). 50% of cases have cirrhosis and 25% die in the first decade of life. A further 2% present with cirrhosis in later childhood. Adult males are at risk of hepatoma development with or without cirrhosis. Diagnosis is by isoelectric focussing or allele-specific oligonucleotide hybridization. The treatment is that of cholestasis and cirrhosis including transplantation. The pathobiology of the deficiency state, the mechanism of liver damage and the vulnerability of the newborn liver are discussed in this review. A plea is made for a trial of infusions of alpha 1-antitrypsin in early infancy, as is used safely but without proven efficacy in the emphysematous PIZZ subject. Prospects of therapy by gene modification are also reviewed.

Sequential histopathologic alterations in Indian childhood cirrhosis treated with d-penicillamine

Eight children who satisfied all the diagnostic criteria of classic Indian childhood cirrhosis were treated with d-penicillamine. Clinical recovery in a 3- to 12-month period was accompanied histopathologically by accentuation of micronodules with regression of hepatocytic degenerative changes, Mallory's hyaline, pericellular fibrosis, lobular inflammation, and disappearance of hepatocytic copper staining protein. The nodules in the posttreatment biopsies were so small as to be categorized as “micro-micronodular cirrhosis.” In one case clinical recovery was associated with an almost normal liver histology after passing through a micronodular phase. This report is the first documentation of the histologic sequence of changes in Indian childhood cirrhosis on d-penicillamine treatment.

Copper and liver disease

There has been some limited progress in the understanding of the basic defect in Wilson disease and the gene concerned has been located to the chromosome region 13q14. Treatment with zinc has emerged as a definite alternative to penicillamine administration and some shortcomings and/or hazards of both forms of therapy have emerged as their modes of action have been studied more carefully. Tetrathimolybdate may have a place in treatment, especially when rapid complexing of copper is important. Hepatic copper accumulation occurs in a number of cholestatic diseases and they play an important part in pathogenesis and can occasionally lead to neurologic toxic effects. Copper overload in the newborn period when biliary excretion of copper is inefficient may establish a vicious cycle of copper accumulation and liver damage in Indian childhood cirrhosis and less frequently in babies in other countries.

Incidence of cirrhosis in children with chronic hepatitis

To determine the incidence of liver cirrhosis in children with chronic hepatitis, we investigated 92 children (64 were girls; mean age was 8 years 2 months) with chronic hepatitis for the presence of cirrhosis by the combined use of laparoscopy and needle liver biopsy, between 1975 and 1985. Forty-six children had hepatitis B virus-related chronic hepatitis; cirrhosis was present in 13 (32%). Cirrhosis was diagnosed by laparoscopy in 14 children and by needle liver biopsy in eight. In six patients, cirrhosis was diagnosed within the first 12 months after the clinical onset of liver disease. Forty-six children had autoimmune hepatitis; cirrhosis was present in 41 (89%). Cirrhosis was diagnosed by laparoscopy in all 41 children and by needle liver biopsy in 23 children. Cirrhosis was already present in all 10 children studied 2 to 5 months after the first sign of liver disease. Our results indicate that the incidence of cirrhosis is high in children with chronic hepatitis, especially of the autoimmune type, and that cirrhosis may occur early, irrespective of cause. A combination of laparoscopy and biopsy is more reliable than biopsy alone for the diagnosis of cirrhosis in children with chronic hepatitis.

Hepatic imaging with computed tomography of chronic tyrosinaemia type 1

Tyrosinaemia type 1 (fumaryl acetoacetase deficiency, hepato-renal tyrosinaemia) is a rare inborn error of metabolism which, in its chronic form, leads to cirrhosis in early childhood and subsequent development of hepatocellular carcinoma in a high proportion of cases. Imaging with computed tomography has an important role in assessing the progress of the liver disease and may be helpful in timing liver transplantation. The radiological features of seven cases are described and the implications discussed.

Alpha-1-antitrypsin: New perspectives and clinical applications

AAT is a 394-residue single chain glycoprotein and functions as the major protease inhibitor of the human body. In this capacity, it prevents neutrophil elastase and other proteolytic enzymes released during inflammatory reactions and during phagocyte death from destroying normal tissues of the body. An inherited, autosomal recessive disorder of AAT is an important cause of emphysema and childhood cirrhosis in individuals of northern European descent. These disorders have been discovered to result from mutations in the AAT gene, located at q31–32.3 on chromosome 14. More than 75 AAT alleles have been identified, some of which are associated with reduced or absent antiprotease activity. Recently, ATT has served as a model for the treatment of human autosomal recessive disorders. This is presently done through the infusion of purified plasma or recombinant AAT. However, in the near future normal human cells may be genetically engineered to produce and secrete the missing molecule.

The difference between human C3F and C3S results from a single amino acid change from an asparagine to an aspartate residue at position 1216 on the alpha chain of the complement component, C3.

The third component of the human C system, C3, exhibits two common genetic variants. These variants have been characterized by high voltage agarose electrophoresis and are designated C3 fast (C3F) and C3 slow (C3S). C3F occurs at appreciable frequencies only in Caucasian populations and has been shown to be associated with an increased incidence of certain diseases, such as partial lipodystrophy, IgA nephropathy, and Indian childhood cirrhosis. It has been shown that C3F differs from C3S with regard to isoelectric point as well as its ability to bind macrophages. The availability of a full-length cDNA probe for human C3 has made it possible to study the polymorphism at the genomic level. We have used RNA/RNA hybridization to demonstrate that the difference between C3F and C3S occurs in the C3d region. We subsequently used oligonucleotide-primed DNA amplification to show that C3F arises from a point mutation at codon 1216 converting a deoxyadenosine for a deoxyguanosine. The result of this point mutation at the translational level is the substitution of an asparagine residue in C3S for an aspartic acid residue in C3F. It is known that C3d contains the binding site for CR2 as well as the internal thioester site and multiple protease cleavage sites. The identification of the structural basis of the differences between C3F and C3S will assist our continuing studies of the mechanism of the functional differences between the two alleles and the disease associations of C3F. It also allows us to use DNA based techniques to allotype C3 in subjects with little or no C3 in their serum.

FAMILIAL' INFANTILE LIVER CIRRHOSIS AND HEMOLYTIC ANEMIA DUE TO CHRONIC COPPER INTOXICATION VIA TAP WATER FROM COPPER PIPES

We report a disease entity which occured in certain areas of West Germany and which was not diagnosed correctly in the past. At present, we are aware of 21 patients (pts) in 15 unrelated families with a total of 45 children. 11 pts died between 8 and 13 months of age, and 6 survived with liver cirrhosis. In the remaining 4 transaminases were initially elevated and turned to normal with correction of drinking water. All families lived in rural areas known for acid ground water. Drinking water was obtained from the own farm's wells with low pH (5.0 - 6.2) and was highly contaminated after passage through copper pipes. All pts were exposed to copper beginning shortly after birth; none of them was breast fed and all received milk formula prepared with the tap water. None of the 24 healthy siblings were exposed during the first three months of life. All pts developed a micronodular liver cirrhosis which resembled the “Indian Childhood Cirrhosis” and which was accompanied by significant copper accumulation in the liver. Common clinical symptoms included: enlargement of liver and spleen, anemia, bleeding disorders, muscular hypotonia. We believe that this disease might occur in other parts of the world if the environmental conditions are similar (acid drinking water and copper piping).

Liver transplantation in children: The initial Toronto experience

The Hospital for Sick Children's initial 2-year experience with pediatric liver transplantation is reviewed. Patients are divided into high- and low-risk groups according to certain criteria. The high-risk group includes patients under 10 kg in weight, those with extrahepatic biliary atresia (EHBA), those with portal vein atresia or thrombosis, and those in hepatic coma. All others were considered low risk. Twenty-nine patients were assessed for transplantation: 18 were transplanted and 6 (21% of total referred) died while on the waiting list. Eighteen patients received 23 transplants. Of the 18 recipients, nine had EHBA, four had fulminant hepatic failure, two had tyrosinemia, one had glycogen storage disease, one had Indian childhood cirrhosis, and one had idiopathic cirrhosis. Seven of the 13 patients in the high-risk group survived (55% survival) with 1 to 23 month follow-up. Survival was significantly higher (80%) in the low-risk group (P less than 0.05). Four patients were retransplanted and two survived. Early deaths occurred from prolonged warm ischemia, recurrent portal vein thrombosis, and brain death in a patient who had been transplanted in hepatic coma. Late deaths occurred from cytomegalovirus (CMV) disease (2 patients), acute rejection (1 patient), and myocardial infarction (1 patient). The incidence of primary nonfunction was 4.3% (1 of 23) and of arterial thrombosis was 13% (3 of 23). Survival in patients transplanted for EHBA (67%) was slightly higher than it was for the rest of the group, although not as good as it was in the low-risk group.(ABSTRACT TRUNCATED AT 250 WORDS)

The difference between human C3F and C3S results from a single amino acid change from an asparagine to an aspartate residue at position 1216 on the alpha-chain of the complement component, C3.

The third component of the human C system, C3, exhibits two common genetic variants. These variants have been characterized by high voltage agarose electrophoresis and are designated C3 fast (C3F) and C3 slow (C3S). C3F occurs at appreciable frequencies only in Caucasian populations and has been shown to be associated with an increased incidence of certain diseases, such as partial lipodystrophy, IgA nephropathy, and Indian childhood cirrhosis. It has been shown that C3F differs from C3S with regard to isoelectric point as well as its ability to bind macrophages. The availability of a full-length cDNA probe for human C3 has made it possible to study the polymorphism at the genomic level. We have used RNA/RNA hybridization to demonstrate that the difference between C3F and C3S occurs in the C3d region. We subsequently used oligonucleotide-primed DNA amplification to show that C3F arises from a point mutation at codon 1216 converting a deoxyadenosine for a deoxyguanosine. The result of this point mutation at the translational level is the substitution of an asparagine residue in C3S for an aspartic acid residue in C3F. It is known that C3d contains the binding site for CR2 as well as the internal thioester site and multiple protease cleavage sites. The identification of the structural basis of the differences between C3F and C3S will assist our continuing studies of the mechanism of the functional differences between the two alleles and the disease associations of C3F. It also allows us to use DNA based techniques to allotype C3 in subjects with little or no C3 in their serum.

Uptake of copper from brass vessels by bovine milk and its relevance to Indian childhood cirrhosis.

To mimic the infant feeding practice associated with Indian childhood cirrhosis (ICC), bovine milk was stored for 6 h in indigenous brass vessels. The milk copper concentration rose from 27 +/- 4 to 621 +/- 65 micrograms/dl, whereas zinc concentration was not significantly changed. Copper in bovine milk was associated with casein (67%), whey proteins (7%), less than 10 kDa molecules (11%), and fat (7%). Addition of copper sulphate to a concentration of 600 micrograms/dl produced a 102-fold rise in copper content of the casein fraction, a 47-fold increase for whey, and 15-fold for the less than 10 kDa fraction. Analysis by sepharose gel chromatography confirmed that casein was the major copper-binding fraction in control and copper-loaded milk. To mimic intragastric conditions, the pH of copper-loaded milk was lowered to 4.5 to precipitate casein, resulting in a rise in less than 10 kDa bound copper (10.7 +/- 4.0 to 104.3 +/- 7.5 micrograms Cu/100 ml) and whey-bound copper (53.1 +/- 4.5 to 118.4 +/- 19.1 micrograms Cu/100 ml). Copper/casein complex (3 micrograms Cu/mg protein, pH 6.6) was dialysed against low-MW metal chelating agents, including picolinate and citrate, which are present in the duodenum. Picolinate 1 mM and citrate 1 mM were able to remove 84% and 29% of copper, respectively. Thus, copper, though not zinc, is avidly taken up from brass and bound largely to casein, from which it is partly liberated by acid precipitation and almost completely removed by picolinate chelation. Milk is an effective carrier of copper from brass utensil to infant enterocyte.

Uptake of Copper from Brass Vessels by Bovine Milk and Its Relevance to Indian Childhood Cirrhosis

To mimic the infant feeding practice associated with Indian childhood cirrhosis (ICC), bovine milk was stored for 6 h in indigenous brass vessels. The milk copper concentration rose from 27 + 4 to 621 + 65 μg/dl, whereas zinc concentration was not significantly changed. Copper in bovine milk was associated with casein (67%), whey proteins (7%), < 10 kDa molecules (11%), and fat (7%). Addition of copper sulphate to a concentration of 600 μg/dl produced a 102‐fold rise in copper content of the casein fraction, a 47‐fold increase for whey, and 15‐fold for the < 10 kDa fraction. Analysis by sepharose gel chromatography confirmed that casein was the major copper‐binding fraction in control and copper‐loaded milk. To mimic intragastric conditions, the pH of copper‐loaded milk was lowered to 4.5 to precipitate casein, resulting in a rise in < 10 kDa bound copper (10.7 + 4.0 to 104.3 + 7.5 μg Cu/100 ml) and whey‐bound copper (53.1 + 4.5 to 118.4 + 19.1 μg Cu/100 ml). Copper/casein complex (3 μg Cu/mg protein, pH 6.6) was dialysed against low‐MW metal chelating agents, including picolinate and citrate, which are present in the duodenum. Picolinate I mM and citrate I mM were able to remove 84% and 29% of copper, respectively. Thus, copper, though not zinc, is avidly taken up from brass and bound largely to casein, from which it is partly liberated by acid precipitation and almost completely removed by picolinate chelation. Milk is an effective carrier of copper from brass utensil to infant enterocyte.

Copper distribution among serum proteins in paediatric liver disorders and malignancies

Fractionation of normal serum on Sephadex G-150, followed by determination of copper, caeruloplasmin and albumin concentrations, indicated that only approximately 71% of total serum copper was associated with caeruloplasmin; less than previously reported values. Seven per cent was associated with a high molecular weight protein, designated 'transcuprein', 19% with albumin and 2% with amino acids. Compared with adult serum the concentrations of caeruloplasmin and of copper associated with caeruloplasmin were low both in serum from neonates and in serum from patients with symptomatic Wilson's disease. However, in contrast to the neonate, Wilson's disease patients exhibited a raised total serum copper and raised non-caeruloplasmin-copper. In Indian Childhood Cirrhosis serum caeruloplasmin and caeruloplasmin-copper levels were normal, whilst the non-caeruloplasmin-copper was raised. Elevated non-caeruloplasmin-copper in Wilson's disease and Indian Childhood Cirrhosis may therefore represent an overspill into the serum from a copper-laden liver. Children with malignancy showed increased serum concentrations of copper and caeruloplasmin. Both caeruloplasmin-bound and non-caeruloplasmin-bound copper concentrations were elevated. It remains to be determined whether increased 'transcuprein'- and albumin-bound copper result from a sequestering of copper released from peripherally utilized caeruloplasmin, or are associated with increased rates of caeruloplasmin synthesis.

Childhood cirrhosis from copper poisoning in the nineteenth century.

Journal of Pediatric Gastroenterology and Nutrition: November 1988 - Volume 7 - Issue 6 - p 934

Copper in urine and hair in Indian childhood cirrhosis.

In advanced Indian childhood cirrhosis (ICC) urine copper concentration was higher (range 416-103,448 mg/g creatinine) than in other hepatic diseases (range 67-10,303 mg/g creatinine). In early ICC urine copper concentration was more modestly raised (1188-9470 mg/g creatinine), but rose to high values (2222-42,819 mg/g creatinine) after a single dose of penicillamine 20 mg/kg. A post-penicillamine urinary copper:creatinine ratio greater than 10,000 mg/g supports a diagnosis of ICC. The concentration of copper in the hair, while increased in advanced ICC, is of no diagnostic value in early cases.

Copper Storage Disease of the Liver and Chronic Dietary Copper Intoxication in Two Further German Infants Mimicking Indian Childhood Cirrhosis

A severe copper storage disease of the liver with micronodular cirrhosis resembling Indian childhood cirrhosis (ICC) was found in two siblings of a German family leading to death in one infant at the age of 13 months. The fatal outcome correlated with severe ballooning of hepatocytes and excessive formation of Mallory bodies. The copper content of the liver was 698 micrograms per gramme wet weight (control 5 micrograms) in the living patient and 2154 micrograms per gramme dry weight (controls 39, 54 micrograms) in the dead infant. In both cases copper was stored not only in hepatocytes but also to a high degree in mesenchymal cells. Chronic contamination of drinking water supplied from a well via copper pipes could be verified as the cause of copper intoxication, lending further support to ICC as an environmental, acquired disorder. Accumulation of exogenic copper already very early in infancy appears most important for the development of the disease, as both the parents and one child not exposed to copper intoxication during the first 9 months of its life are clinically healthy.

Reversal of malnutrition in childhood cirrhosis by intensive enteral feeding

Reversal of malnutrition in childhood cirrhosis by intensive enteral feeding

Hypothesis: plant and fungal biocides, copper and Indian childhood liver disease

Hepatic copper accumulation is characteristic of Indian childhood cirrhosis (ICC) but in experimental animals causes only modest liver damage. Plant and fungal biocidal agents may be hepatotoxic, may increase hepatic copper concentration, and may be secreted in milk of lactating animals. Crotalaria species, Parthenium hysterophorus and Aspergillus flavus are possible contaminants of animal feeds in rural India, and we hypothesise that their products may be synergistic with copper in causing ICC.

Enzymatic studies and isoenzyme pattern of gammaglutamyl transpeptidase (GGTP) in Indian childhood cirrhosis (CC).

Histopathological studies of liver cell showing necrosis, parenchymal cell injury and microsomal cell damage are known to affect membrane bound enzymes such as gamma-glutamyl transpeptidase (GGTP), alkaline phosphatase (AP) and 5′-nucleotidase (5′-NT). The significant rise in GGTP, AP and 5′-NT indicates the damage of microsomes of parenchymal cell in Indian Childhood Cirrhosis (ICC) patients. SGPT/AP ratio may be an index for distinguishing ICC with other liver diseases. The isoenzyme pattern of GGTP in sera of control and ICC subjects have one band prominent activity. Similarly biopsy samples of control and ICC subjects show one prominent band of GGTP activity. The appearance of isoenzyme of GGTP in blood circulation is an index of microsome damage, cell necrosis and parenchymal cell injury. The isoenzyme pattern of GGTP could be a diagnostic test for ICC.

Idiopathic Hepatic Copper Toxicosis in a Child

SummaryA 10‐year‐old Italian boy with chronic liver disease and copper overload is described. Biological and histopathological findings are similar to those described in children with Indian childhood cirrhosis. This report suggest that a disease akin to Indian childhood cirrhosis but different from Wilson disease can be found in non‐Indian children probably representing a new, possibly inherited, disease of copper metabolism leading to copper overload in the liver.