Evaluation Of Liver Histology Research Articles

Development of a Humanized Mouse Model of Cholestatic Sickle Cell Disease

Sickle cell disease (SCD) is a group of autosomal recessive inherited disorders that affect approximately 100,000 people in the United States and millions worldwide. Liver or biliary complications including cirrhosis and cholestatic injury are evident in about 40% of hospitalized SCD patients. However, the molecular mechanisms responsible for sickle cell hepatopathy (SCH) remain poorly understood. Recently published studies and our preliminary data demonstrated impaired bile secretion and altered bile acid homeostasis accompanied red blood cell sequestration and fibrosis in the livers of humanized sickle cell mice. Although promising, a limitation of this model for the study of SCH is the predominance of hydrophilic bile acids in mice, which contrasts with a more hydrophobic and injurious bile acid pool in humans. A recent breakthrough in this area was the identification of murine-specific cytochrome P450 (Cyp2c70) as the enzyme responsible for the synthesis of mouse hydrophilic primary bile acids. Therefore, we hypothesize that the human hydrophobic bile acid composition would promote the development of cholestatic sickle cell disease. Methods:Tibias and femurs were excised from 2-month-old SCD SS and AA control mice and the bone marrow (BM) was collected. After lethal irradiation (2x 4.5Gy 4 hours apart), 2-month-old male recipient Cyp2c70-/- and their wildtype controls received BM-derived cells from either AA or SS mice. Cyp2c70-/- (KO) mice (C57Bl/6) were generated using CRISPR/Cas9 technology. Recipient Cyp2c70-/- and WTmice were reconstituted with SS and AA bone marrow and were euthanized 4 months after BMT. Standard growth parameters were recorded; liver, spleen, gallbladder bile, and blood were collected at necropsy for histologic, RNA, and chemical analyses. Results: Recipient Cyp2c70-/- (KO) SS mice had a significantly increased liver-to-body weight ratio compared to their controls. There was an increase in serum bile acids, direct bilirubin, and total bilirubin in SS recipient Cyp2c70-/- and WT mice compared to AA recipient mice. Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were increased in Cyp2c70-/- (KO) overall with no observable difference in Cyp2c70-/- (KO) transplanted with AA or SS. An evaluation of liver histology by H&E revealed increased portal bridging and hepatic sequestration in sinusoids of recipient Cyp2c70-/- SS mice compared to control mice. Liver surface nodularity and morphological heterogeneity were also present in recipient Cyp2c70-/- SS mice compared to their controls. We observed increased collagen deposition as measured by Sirius Red staining in recipient Cyp2c70-/- SS mice compared to control mice. Liver histology revealed increased hepatic inflammation by F4/80 staining and bile duct proliferation by CK-19 and CK-8 staining in recipient Cyp2c70-/- SS mice. Conclusion: Coupled with the humanized sickle cell disease mouse, this novel sickle cell cholestatic liver mouse model can be used to investigate the role of hydrophobic bile acid-induced injury in sickle cell-related hepatobiliary disease and screen new therapeutic approaches for SCH. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Ileal bile acid transporter inhibition in Cyp2c70 KO mice ameliorates cholestatic liver injury

Cyp2c70 is the liver enzyme in rodents responsible for synthesis of the primary 6-hydroxylated muricholate bile acid (BA) species. Cyp2c70 KO mice are devoid of protective, hydrophilic muricholic acids, leading to a more human-like BA composition and subsequent cholestatic liver injury. Pharmacological inhibition of the ileal BA transporter (IBAT) has been shown to be therapeutic in cholestatic models. Here, we aimed to determine if IBAT inhibition with SC-435 is protective in Cyp2c70 KO mice. As compared to WT mice, we found male and female Cyp2c70 KO mice exhibited increased levels of serum liver injury markers, and our evaluation of liver histology revealed increased hepatic inflammation, macrophage infiltration, and biliary cell proliferation. We demonstrate serum and histologic markers of liver damage were markedly reduced with SC-435 treatment. Additionally, we show hepatic gene expression in pathways related to immune cell activation and inflammation were significantly upregulated in Cyp2c70 KO mice and reduced to levels indistinguishable from WT with IBAT inhibition. In Cyp2c70 KO mice, the liver BA content was significantly increased, enriched in chenodeoxycholic acid, and more hydrophobic, exhibiting a hydrophobicity index value and red blood cell lysis properties similar to human liver BAs. Furthermore, we determined IBAT inhibition reduced the total hepatic BA levels but did not affect overall hydrophobicity of the liver BAs. These findings suggest that there may be a threshold in the liver for pathological accretion of hydrophobic BAs and reducing hepatic BA accumulation can be sufficient to alleviate liver injury, independent of BA pool hydrophobicity.

Growth performance and fatty acid tissue profile in gilthead seabream juveniles fed with different phospholipid sources supplemented in low-fish meal diets

The aim of the present study was to evaluate the phospholipid requirements for gilthead seabream, fed with low-fish meal diets. A 70-day feeding trial was performed to evaluate the dietary effects of marine versus plant-based phospholipid sources in low-fish meal diets on growth, body composition, liver, muscle and intestinal fatty acid profiles (polar and neutral), as well as liver morphology. Three levels of krill (marine) or soy lecithin (plant) as phospholipid source, at 0.53%, 1% and 2%, were supplemented in diets with 10% fish meal inclusion. The effects were compared to a high-fish meal diet (65%) as a positive control, and a low-fish meal diet without addition of phospholipids as a negative control. Growth, feed and protein efficiency parameters were improved by the addition of phospholipids in the low-fish meal diets, irrespective of the source, but all parameters were lower compared to the positive control. Krill phospholipid supplementation showed optimal results at 0.5% levels and soybean lecithin supplementation at 1% level. Significant differences by the phospholipid supplementation were found in both the neutral and polar lipid profile in the liver and muscle, while only in the neutral lipids in the intestine. Evaluation of liver histology indicated mild improvement of steatosis symptoms. Overall, our results indicate that phospholipid supplementation in low-fish meal diets can improve the growth and liver status in gilthead seabream juveniles.

Neem Leaf (Azadirachta indica A. Juss) Ethanolic Extract on the Liver and Kidney Function of Rats.

Neem (Azadirachta indica A. Juss) is one of the tropical plants found in Indonesia that has been used to prevent and treat various diseases. This study aimed to investigate the effect of the ethanol extract of neem leaves on the concentration of aspartate aminotransferase (AST), alanine aminotransferase (ALT), urea, and creatinine in male rats. Twenty-four male Wistar rats were randomly divided into four groups (T0, T1, T2, and T3) with 6 rats in each group. T0 is the control group, and T1, T2, and T3 are the treatment groups that were administered 100, 200, and 300 mg/kg body weight of neem leaf ethanolic extracts for 48 days, respectively. On day 49, blood samples were collected to measure the concentration of AST, ALT, creatinine, and urea followed by an evaluation of liver and kidney histology. The results showed that the ethanolic extract of neem leaves did not affect the concentration of AST, ALT, and creatinine, The ethanol leaves reduced extract on the urea concentration, no abnormal changes were observed in the liver and kidney organs. In the future, it is required to carry out a comprehensive safety evaluation of the neem leaf ethanol extract for herbal medicines.

Report on the AASLD/EASL Joint Workshop on Clinical Trial Endpoints in NAFLD.

Nonalcoholic fatty liver disease (NAFLD) is a global public health concern. Its natural history, the development of nonalcoholic steatohepatitis (NASH) and fibrosis, is highly variable, prone to endogenous (e.g., genetics, microbiota) and exogenous (e.g., nutrition, alcohol, physical activity) disease modifiers, and can fluctuate over time. The complexity of its pathophysiology is reflected by the multitude of pharmacological targets in development. NASH clinical trials have provided valuable insight that is applicable to future trial design. Endpoints for NASH have evolved over the past decade and will continue to be refined. Currently accepted endpoints for conditional approval include resolution of NASH without worsening of fibrosis and/or improvement in fibrosis without worsening of NASH by standardized evaluation of paired liver histology. In pediatric NASH, practical obstacles, pubertal hormonal changes, and stringent safety requirements mandate adaptations in trial design. In adult patients with NASH-related cirrhosis, clinical events (e.g. decompensation, hepatocellular carcinoma, transplantation, death) are more prevalent and thereby are viable primary endpoints. Consideration of the natural fluctuation of disease, the clinical implication of the chosen primary endpoint, and factors that may affect placebo response will facilitate an accurate determination of efficacy of emerging therapeutics for NASH. Conclusion: The June 2018 American Association for the Study of Liver Diseases and European Association for the Study of the Liver joint workshop on NAFLD endpoints summarized important findings from ongoing and completed trials, defined the scientific evidence supporting distinct endpoints, and provided guidance for future trial design.

The liver protection of propylene glycol alginate sodium sulfate preconditioning against ischemia reperfusion injury: focusing MAPK pathway activity

Hepatic ischemia reperfusion (IR) injury contributes to the morbidity and mortality associated with liver surgery. This study investigated the protective function and mechanism of propylene glycol alginate sodium sulfate (PSS), a sulfated polysaccharide, in a mouse hepatic IR injury model. PSS (25 or 50 mg/kg) or saline were injected intraperitoneally to male Balb/c mice 1 h before 45 min of 70% warm hepatic ischemia and 2, 8, and 24 h of reperfusion. Serum and liver tissue samples were collected for evaluation of hepatocellular damage, liver histology, and assay of inflammatory cytokines, apoptosis- and autophagy-related proteins, and proteins in the mitogen-activated protein kinase (MAPKs). Histological injury and release of transaminases, and inflammatory cytokine production were significantly reduced by PSS pretreatment. The expression of apoptosis- and autophagy-related proteins, and the activation of MAPK signal, including jun N-terminal kinase (JNK), extracellular signal-regulated kinase (ERK), and P38 were all affected by PSS treatment compared with IR model controls. PSS protected the liver from IR injury by suppressing the MAPK signaling and down-regulating inflammation, apoptosis, and autophagy.

Precise evaluation of liver histology by computerized morphometry shows that steatosis influences liver stiffness measured by transient elastography in chronic hepatitis C

Liver stiffness evaluation (LSE) by Fibroscan is now widely used to assess liver fibrosis in chronic hepatitis C. Liver steatosis is a common lesion in chronic hepatitis C as in other chronic liver diseases, but its influence on LSE remains unclear. We aimed to precisely determine the influence of steatosis on LSE by using quantitative and precise morphometric measurements of liver histology. 650 patients with chronic hepatitis C, liver biopsy, and LSE were included. Liver specimens were evaluated by optical analysis (Metavir F and A, steatosis grading) and by computerized morphometry to determine the area (%, reflecting quantity) and fractal dimension (FD, reflecting architecture) of liver fibrosis and steatosis. The relationships between LSE and liver histology were better described using morphometry. LSE median was independently linked to fibrosis (area or FD), steatosis (area or FD), activity (serum AST), and IQR/LSE median. Steatosis area ≥4.0 % induced a 50 % increase in LSE result in patients with fibrosis area <9 %. In patients with IQR/LSE median ≤0.30, the rate of F0/1 patients misclassified as F ≥ 2 by Fibroscan was, respectively for steatosis area <4.0 and ≥4.0 %: 12.6 vs 32.4 % (p = 0.003). Steatosis level did not influence LSE median when fibrosis area was ≥9 %, and consequently did not increase the rate of F ≤ 3 patients misclassified as cirrhotic. A precise evaluation of liver histology by computerized morphometry shows that liver stiffness measured by Fibroscan is linked to liver fibrosis, activity, and also steatosis. High level of steatosis induces misevaluation of liver fibrosis by Fibroscan.

Mini-laparoscopy in the endoscopy unit

The evaluation of liver histology is an important component of the diagnosis and staging of liver diseases. The most common technique employed to sample liver tissue for decades has been percutaneous liver biopsy. Although this is a relatively well tolerated technique in the early stages of liver disease, it carries a high risk of complications, particularly hemorrhage, in patients with advanced cirrhosis. Mini-laparoscopy allows macroscopic assessment and biopsy under direct vision and therefore is a well tolerated and effective technique. The major advantages of this technique are direct visualization of the liver surface, thereby allowing inspection for morphologic changes of cirrhosis as well as targeted biopsies, the ability to immediately treat potential complications (bleeding and bile leakage), furthermore the peritoneal cavity can be visualized to stage gastrointestinal (GI) malignancies. Additionally, 'blind' percutaneous liver biopsy fails to establish a diagnosis in about 25% of cases, largely because of sampling error. This technique presents the opportunity to visualize the surface of the liver and the peritoneal cavity, making it a valuable tool for liver biopsy. This review summarizes the technique of mini-laparoscopy and addresses its potential uses and limitations as a diagnostic modality.

Up-regulation of MicroRNA-155 in Macrophages Contributes to Increased Tumor Necrosis Factor α (TNFα) Production via Increased mRNA Half-life in Alcoholic Liver Disease

Activation of Kupffer cells (KCs) by gut-derived lipopolysaccharide (LPS) and Toll-Like Receptors 4 (TLR4)-LPS-mediated increase in TNFα production has a central role in the pathogenesis of alcoholic liver disease. Micro-RNA (miR)-125b, miR-146a, and miR-155 can regulate inflammatory responses to LPS. Here we evaluated the involvement of miRs in alcohol-induced macrophage activation. Chronic alcohol treatment in vitro resulted in a time-dependent increase in miR-155 but not miR-125b or miR-146a levels in RAW 264.7 macrophages. Furthermore, alcohol pretreatment augmented LPS-induced miR-155 expression in macrophages. We found a linear correlation between alcohol-induced increase in miR-155 and TNFα induction. In a mouse model of alcoholic liver disease, we found a significant increase in both miR-155 levels and TNFα production in isolated KCs when compared with pair-fed controls. The mechanistic role of miR-155 in TNFα regulation was indicated by decreased TNFα levels in alcohol-treated macrophages after inhibition of miR-155 and by increased TNFα production after miR-155 overexpression, respectively. We found that miR-155 affected TNFα mRNA stability because miR-155 inhibition decreased whereas miR-155 overexpression increased TNFα mRNA half-life. Using the NF-κB inhibitors, MG-132 or Bay11-7082, we demonstrated that NF-κB activation mediated the up-regulation of miR-155 by alcohol in KCs. In conclusion, our novel data demonstrate that chronic alcohol consumption increases miR-155 in macrophages via NF-κB and the increased miR-155 contributes to alcohol-induced elevation in TNFα production via increased mRNA stability.

A Case Report of Hepatic Tuberculosis

Background: Pulmonary tuberculosis (TB) is one of the common infections in developing countries of Asia and Africa, however, little isknown about hepatic tuberculosis from these countries.Case report: We report a case of hepatic tuberculosis in a 24-year-old Bangladeshi man. He attended the physician for evaluation ofhepatitis B surface antigen. He was asymptomatic with no notable hepatic and pulmonary complains. A diagnosis of hepatic TB was madeafter evaluation of liver histology that exhibited epitheloid granuloma with central caseating necrosis in the liver. The patient was successfullytreated by antitubercular drugs.Discussion: Involvement of liver in TB may occur in a variety of forms. The commonest form is disseminated tuberculosis. A second varietyrepresents diffuse involvement of liver with granuloma formation (granulomatous hepatitis). This is the first reporting of hepatic TB fromBangladesh, a country that harbors millions of people infected with TB and hepatitis viruses.Abbreviations: TB-Tuberculosis; HBV-Hepatitis B virus; HBsAg-Hepatitis B surface antigen; HAI-Histology activity index; AFB-Acid fastbacili.

Collaborative study on fifteen compounds in the rat-liver Comet assay integrated into 2- and 4-week repeat-dose studies

A collaborative trial was conducted to evaluate the possibility of integrating the rat-liver Comet assay into repeat-dose toxicity studies. Fourteen laboratories from Europe, Japan and the USA tested fifteen chemicals. Two chemicals had been previously shown to induce micronuclei in an acute protocol, but were found negative in a 4-week Micronucleus (MN) Assay (benzo[ a]pyrene and 1,2-dimethylhydrazine; Hamada et al., 2001); four genotoxic rat-liver carcinogens that were negative in the MN assay in bone marrow or blood (2,6-dinitrotoluene, dimethylnitrosamine, 1,2-dibromomethane, and 2-amino-3-methylimidazo[4,5-f]quinoline); three compounds used in the ongoing JaCVAM (Japanese Center for the Validation of Alternative Methods) validation study of the acute liver Comet assay (2,4-diaminotoluene, 2,6-diaminotoluene and acrylamide); three pharmaceutical-like compounds (chlordiazepoxide, pyrimethamine and gemifloxacin), and three non-genotoxic rodent liver carcinogens (methapyrilene, clofibrate and phenobarbital). Male rats received oral administrations of the test compounds, daily for two or four weeks. The top dose was meant to be the highest dose producing clinical signs or histopathological effects without causing mortality, i.e. the 28-day maximum tolerated dose. The liver Comet assay was performed according to published recommendations and following the protocol for the ongoing JaCVAM validation trial. Laboratories provided liver Comet assay data obtained at the end of the long-term (2- or 4-week) studies together with an evaluation of liver histology. Most of the test compounds were also investigated in the liver Comet assay after short-term (1–3 daily) administration to compare the sensitivity of the two study designs. MN analyses were conducted in bone marrow or peripheral blood for most of the compounds to determine whether the liver Comet assay could complement the MN assay for the detection of genotoxins after long-term treatment. Most of the liver genotoxins were positive and the three non-genotoxic carcinogens gave negative result in the liver Comet assay after long-term administration. There was a high concordance between short- and long-term Comet assay results. Most compounds when tested up to the maximum tolerated dose were correctly detected in both short- and long-term studies. Discrepant results were obtained with 2,6 diaminotoluene (negative in the short-term, but positive in the long-term study), phenobarbital (positive in the short-term, but negative in the long-term study) and gemifloxacin (positive in the short-term, but negative in the long-term study). The overall results indicate that the liver Comet assay can be integrated within repeat-dose toxicity studies and efficiently complements the MN assay in detecting genotoxins. Practical aspects of integrating genotoxicity endpoints into repeat-dose studies were evaluated, e.g. by investigating the effect of blood sampling, as typically performed during toxicity studies, on the Comet and MN assays. The bleeding protocols used here did not affect the conclusions of the Comet assay or of the MN assays in blood and bone marrow. Although bleeding generally increased reticulocyte frequencies, the sensitivity of the response in the MN assay was not altered. These findings indicate that all animals in a toxicity study (main-study animals as well as toxicokinetic (TK) satellite animals) could be used for evaluating genotoxicity. However, possible logistical issues with scheduling of the necropsies and the need to conduct electrophoresis promptly after tissue sampling suggest that the use of TK animals could be simpler. The data so far do not indicate that liver proliferation or toxicity confound the results of the liver Comet assay. As was also true for other genotoxicity assays, criteria for evaluation of Comet assay results and statistical analyses differed among laboratories. Whereas comprehensive advice on statistical analysis is available in the literature, agreement is needed on applying consistent criteria.

Tyrosinemia Type 1: Metastatic Hepatoblastoma With a Favorable Outcome

The clinical course of tyrosinemia type 1 is characterized by acute liver failure in infancy or chronic liver dysfunction and renal Fanconi syndrome in late-presenting cases. Dietary treatment may improve liver function but does not prevent the development of hepatocellular carcinoma (HCC) in late childhood. A new treatment strategy that uses 2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione (NTBC), which prevents the production of toxic/carcinogenic metabolites, has dramatically changed the outcome of the disease by reducing the occurrence of liver cancer, especially in patients who start this treatment before the age of 2 years. We report here the case of a patient with a diagnosis of tyrosinemia type 1 at 5 months of age who was treated with NTBC and dietary restriction and in whom a liver neoplasm with lung metastases, histologically determined to be HCC, was found at the age of 15 months. A conservative approach that consisted of chemotherapy and partial hepatectomy resulted in a 12-year disease-free period. The excellent postchemotherapy course, in sharp contrast to the expected course of HCC, led to histologic reevaluation with reclassification of the neoplasm as hepatoblastoma. A diagnosis of hepatoblastoma would no longer be a mandate for a liver transplant for patients with tyrosinemia type 1 undergoing NTBC treatment. We encourage clinicians to perform more accurate evaluation of liver histology, because a neoplastic mass in a child with tyrosinemia type 1 is not the same as HCC.

High-dose ursodeoxycholic acid therapy for nonalcoholic steatohepatitis: a double-blind, randomized, placebo-controlled trial

In uncontrolled clinical studies, ursodeoxycholic acid (UDCA) had a beneficial effect on nonalcoholic steatohepatitis (NASH). However, a large controlled trial using UDCA (13-15 mg/kg/day) was unable to confirm these results. Accordingly, a randomized, placebo-controlled study was initiated with a high dose of UDCA (23-28 mg/kg/day). The allocation of patients and the evaluation of liver histology were performed according to a modified Brunt score and the nonalcoholic fatty liver disease activity score (NAS). With the modified Brunt score, 185 patients with histologically proven NASH were randomized [intention to treat (ITT)], and 147 were treated per protocol (PP). With the NAS, 137 patients were confirmed to have NASH, 48 had borderline NASH, and 1 did not have NASH. The treatment time was 18 months. At entry, the treatment groups were comparable. A second biopsy sample was obtained from 139 of 185 patients (NAS: 107/137). The primary criterion for evaluation was a change in the liver histology; the secondary criteria were single histological variables and liver biochemistry. Significant differences in the overall histology could not be detected between the two treatment groups with the modified Brunt score (P = 0.881) or NAS (P = 0.355). Only lobular inflammation improved significantly (P for the modified Brunt score = 0.011, P for NAS = 0.005). In subgroup analyses, significant improvements in lobular inflammation were also observed in males, younger patients up to 50 years of age, slightly overweight patients, and patients with hypertension and an increased histology score. The fibrosis score did not change (P for ITT = 0.133, P for PP = 0.140). With the exception of gamma-glutamyl transferase, UDCA did not improve laboratory data. High-dose UDCA failed to improve the overall histology in patients with NASH in comparison with placebo.

Comparison of ethyl glucuronide in hair with phosphatidylethanol in whole blood as post-mortem markers of alcohol abuse

Ethyl glucuronide (EtG) is a direct metabolite of ethanol and has been used as a marker of alcohol abuse in both urine and hair. This study investigated the value of EtG testing in post-mortem hair for diagnostic improvement of alcohol abuse in forensic medicine. Material from 70 consecutive medico-legal autopsies was collected in accordance with the recommendations on ethics by the Swedish National Board of Forensic Medicine. A method for determination of EtG in hair samples was developed using ultra performance liquid chromatography/electrospray tandem mass spectrometry (UPLC/ESI-MS/MS; LOQ, 2.5 pg/mg). The result of the EtG analysis was compared with the findings of phosphatidylethanol (PEth) in femoral whole blood, as measured by high performance liquid chromatography with an evaporative light-scattering detector (HPLC–ELSD; LOQ, 0.22 μmol/l). Evaluation of liver histology and anamnestic evidence of alcohol abuse of the deceased were taken in consideration for the interpretation. Measurable levels of EtG were present in 49 of the 70 autopsy cases whereas PEth was present in 36. Thirty-nine cases had EtG levels above the cutoff limit (≥30 pg/mg) compared with 29 for PEth (≥0.7 μmol/l). Fifteen cases had EtG as exclusive indicator for alcohol abuse compared with four cases for PEth. These findings suggest that measurements of EtG in hair may provide improved diagnostic information on alcohol abuse, due to a long retrospective time-window for detection and stability of EtG in hair in the decaying cadaver. However, an EtG level below the cutoff does not completely exclude previous alcohol abuse.

Experts' opinions on the role of liver biopsy in HCV infection: A Delphi survey by the Italian Association of Hospital Gastroenterologists (A.I.G.O.)

Liver biopsy represents the gold standard to establish a diagnosis in all liver patients, but its current position in chronic viral hepatitis is questioned. We aimed to create a consensus on best practice of use of liver biopsy in the management of chronic HCV infection. We applied the Delphi method to 12 clinical scenarios of chronic HCV infection, to assess the extent of agreement (consensus measurement) and to resolve disagreement (consensus development) on the appropriateness of liver biopsy. Among 108 chosen hepatologists, 61 (56.5%) accepted to participate to the first-round survey. In four patients the majority of experts (from 61.4 to 86.2%) agreed not to perform liver biopsy; in two cases an equivalent opinion was found, and in the remaining six scenarios the majority of experts would have recommended a biopsy. No expert recommended liver biopsy in all cases, while most agreed for an histological evaluation of 4 to 8 cases. At the second round, 36 experts (59%) submitted ballots. Fifty-four out of 431 (12.6%) original judgments were changed with equal distribution among different scenarios. Our survey showed a great divergence of management of similar patients and should provide a stimulus for an evidence-based evaluation of liver histology in chronic HCV infection.

Ileal exclusion for Byler's disease: An alternative surgical approach with promising early results for pruritus

Background/Purpose: Progressive familial intrahepatic cholestasis (Byler's disease) is often characterized by pruritus-induced self-mutilation with minimal response to medical therapy. The causative cholestasis is likely to progress to cirrhosis necessitating transplantation. Partial external biliary diversion has been used with promising results for the jaundice and debilitating pruritus but all the potential complications and aesthetic concerns of long-term stomas attend this approach. Methods: The authors describe a terminal ileal exclusion that was first developed for patients who had previously undergone cholecystectomy. Over a 3-year period, we identified for study seven children with liver histology characteristic of Byler's disease accompanying a clinical picture of chronic cholestasis without a defined metabolic or anatomic abnormality. The first two patients underwent a cholecystojejunal cutaneous stoma, until now, the recommended treatment for this condition. The third had previously undergone cholecystectomy so an ileocolonic anastomosis was performed excluding the distal 15% of the small bowel. This child had complete relief of pruritus without evidence of diarrhea. Two more terminal ileal exclusions were performed with similar results before standardizing this approach. The authors approximated small intestinal length using Siebert's graph relating crown-heel length to small intestinal length. The midpoint between the mean and one standard deviation below the mean was determined. Fifteen percent of the estimated small bowel length was measured back from the ileocecal valve and then divided using a linear stapling device. A stapled anastomosis was created between the proximal ileum and the cecum, bypassing the terminal ileum. Results: Four of five children have had relief from their pruritus and self-mutilation with no evidence of diarrhea. Terminal ileal bypass offers a stoma-free, completely reversible “biliary diversion”. Conclusion: Early results on a few patients are promising, but long-term evaluation of growth, development, and liver function and histology is needed before advocating this as the primary therapy for Byler's disease.

Liver Dysfunction in Children and Adolescents During Hemodialysis and After Renal Transplantation

Liver dysfunction is common in patients on hemodialysis or during the posttransplant period. Twelve children in the End-Stage Renal Disease Program at the University of Florida ranging in age from 4 to 18 years, developed persistent, elevated liver enzymes (SGOT or SGPT greater than 100 IU/liter) during hemodialysis in preparation for renal transplantation. Eleven of 12 developed enzyme elevations within six weeks of the initiation of hemodialysis. The other child exhibited enzyme elevations after one year on dialysis while awaiting a second transplant. Most of the children were anicteric and asymptomatic. Potential hepatotoxic drugs were discontinued when serum transaminase elevations were noted. Hepatitis B surface antigenemia was associated with enzyme elevations in one patient; cytomegalovirus seroconversion had occurred in eight patients, but only three had associated enzyme elevations. Liver biopsies were performed in all the patients before or at the time of renal transplantation. The histology was variable and ranged from normal in six patients, mildly abnormal with changes compatible with acute hepatitis in four patients, and granulomatous hepatitis in one patient, to severely abnormal with chronic hepatitis inthe remaining patient. Seven of the 12 children underwent successful transplantation with return of enzyme levels to normal in five and persistent elevations in the others. These findings suggest that evaluation of liver histology provides the only accurate means of assessment of persistent liver dysfunction in children and adolescents on hemodialysis and after renal transplantation.