Prof. Anil Dhawan MD FRCPCH
Director , King’s Cell Therapy Unit
Director Paediatric Liver GI and Nutrition Centre
Liver disease in Infants
Neonatal Hepatitis 1970-1990
N=1086
Neonatal Hepatitis 1992-2005
N=1625
Neonatal
Cholestasis
~ 1:2700
live
births
Infantile Cholestasis
Disease specific tests (about 30%)• Metabolic
• Perinatal infections
• Endocrinopathies
• Choledochal cysts
• Others
Infantile Cholestasis
70% of patients no single test • Biliary atresia
• Idiopathic neonatal hepatitis
• Alagille
• Others
Liver biopsy constitutes a major piece of ZIG SAW
Infantile Cholestasis
Aim of Investigations
v Identify Treatable Condition
v Recognise Complications
v Early Referral
Infantile Cholestasis
Clinical Clues
v Cutaneous haemangioma -Liver
haemangioma
v Cystic mass -Choledochal
cyst
v Micropenis -SOD
v White hair -HLH
v Ascites -Spon.perf. of bile
duct Storage
disorder,
congenital heart, HLH,
hypothyroidism, Alpha-
1- anti trypsin def.
Infantile Cholestasis
Subsequent Investigations
v Alpha-1 antitrypsin phenotype
v Gal-1 phosphate uridyl transferase
v Urine succinyl acetone (delta amino laevulinic acid)
v Serum and urine amino acids
v Serum Cholesterol and triglycerides
v TSH/T4, Cortisol
v Sweat sodium/IRT/Mutational analysis for CF
v TORCH(S) screen
v Hep Bs Ag, hep C Ab, HIV Ab and other viruses
v x-ray long bones and spine
v MRI or CT scan of head
v
look normal!!
babies with biliary atresia
Infantile Cholestasis
Prelaparatomy diagnosis of biliary
atresiav Stool colour
v Ultrasound
v Hepatobiliary scintigraphy
v ERCP
v MRCP
v Duodenal aspiration
v Liver biopsy
prevalence of jaundice in UK
v Incidence.
– 2 - 15% will remain
jaundiced after 14
days.
– 0.2 - 0.4% will be
conjugated.
v 1 in 17,000 live births
will have biliary atresia
Livesey et al. 2009.
Biliary atresia
Incidence
1:14,000 -1:21,000
Single commonest indication for LTx in children
Biliary atresia
1892
John Thompson -
Edinburgh physician
Gallbladder
Bile Duct Remnants
Classification
Type 2 (~2%)
Type 1 (~8%)
Type 3 (~90%)
JAPS
Kasai’s operation - 1959
v Morio Kasai
v Surgery for
“uncorrectable”(>80%) type of
biliary atresia
Liver Transplantation - 1963
Kasai portoenterostomy
“Complementary
& seamless”Davenport et al. Lancet 2004
Liver transplantation
Early diagnosis - liver biopsy / ERCP
Overt
cirrhosis
current management
“maximally invasive surgery”
Biliary atresia
successfu
l
Kasai
portoenterostomy
unsuccessf
ul
jaundice cleared
jaundice not cleared
pe
rce
nta
ge
su
rviv
al
Biliary atresia
jaundice cleared
jaundice not cleared
pe
rce
nta
ge
su
rviv
al
Biliary atresia
Cryptogenic hepatitis
331
Infant Cholestasis
Biliary atresia
337
Alpha-1 anti trypsin deficiency
189Alagille syndrome
61Choledochal cyst
34Others
94Total
1046
King’s Data n=1046
Infant Cholestasis
Giant cell hepatitis
Infant Cholestasis
Cryptogenic neonatal hepatitis
progression to chronic liver disease
20%
complete resolution 80%
Infant Cholestasis
Cryptogenic neonatal hepatitis
Indicators of poor prognosis
cirrhosis/severe fibrosis
at presentation
parental consanguinity
low gGT
positive family history
Biochemistry
Molecular
genetics
PC
Hepatocyte
OCT
NTCP OATP
OC
BA OA
MDR2/3
OA
MRP2
BSEP
BA
FIC1
MDR1
PS?
Cholangiocyte
CFTR AE
Cl-
Cl-
Cl-
HCO3-
AQPBA
ASBTH2O
NSC?
Bile
flow
PL
Ch
ABCG5/8
MRPs
*
*
*
*
Low γGT cholestatic liver disease
progressive familial intrahepatic
cholestasis:
BSEP deficiency
FIC1 deficiency
29% not accounted for
1º or 2º bile acid synthesis defects
= failure of bile acid secretion
Bile salt export pump (BSEP)
deficiency
ABCB11 gene on chromosome
2q24-31
function: major bile salt export
pump
exclusively hepatic phenotype
presents with a neonatal hepatitis
FIC1 deficiency
protein: P-type
ATPase
ATP8B1 gene on chromosome
18q21
function: aminophospholipid flipase?
hepatic and extrahepatic phenotype:
malabsorption, pancreatitis, growth failure
Raised γGT cholestasis
primary inflammatory, weak genetic
factors
– PSC, PBC, infective, biliary atresia
cholangitis / cholangiopathy
genetic
– MDR3 deficiency (ABCB4)
– North American Indian childhood
cirrhosis
– neonatal sclerosing cholangitis
General Management
v MCT rich formulae
v Vitamin K
v Vitamin A, E and D
v ? UCDA and other choleretic agents in selected patients
v Anti-pruritic agents and biliary diversion
v Transplantation
Paediatric Acute Liver
Failure
Professor Anil Dhawan MD, FRCPCH
Consultant Paediatric Hepatologist
King’s College London School of Medicine
King’s College Hospital
London
Definition
Multisystem disorder in which severe
acute impairment of liver function
(INR>2)
with or without encephalopathy
occurs in association with hepatocellular
necrosis in a patient with no
recognised underlying chronic liver
disease
Acute liver failure in childhood
Pediatric ALF: Age of Onset
0
10
20
30
40
50
60
70
80
<1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Age (years)
(N = 331)
Aetiology of ALF in children
KCH data
n=236 (1992-2004)
31%
15%
11%
8%
7%
6%
6%
5%
3%3%
3%2% Indeterminate
POD
Infectious
Metabolic
NNH
AILD
Drug induced
Wilson's disease
Hypoxia/ischaemia
HLH
VOD
Miscellaneous
Neonatal Liver Failure
165
43 1 1 1 1 1
Haemochromatosis
HSV
HLH
Galactosaemia
Tyrosinaemia
OTC def
Sepsis
Paracetamol
Hypocortisolism
Diagnostic difficulties
• Investigations aimed at-
– Establishing the diagnosis
– Exclude conditions not treatable by liver
transplantation
Acute Liver Failure
Bone Marrow ExamHLH
ALL
NPC
Pearson
Syn
Value of liver
biopsy??
Neonatal Haemochromatosis
Gestational alloimmune liver
disease• Severe liver disease of intrauterine onset
associated with extrahepatic siderosis that
spares reticuloendothelial system.
Neonatal Haemochromatosis
Gestational alloimmune liver
disease• Prenatal onset
• Rarely affects first born
• Highly recurrent in subsequent
pregnancies
• Associated with maternal antibody to
foetal liver antigen
‘Liver Dialysis’
bridge to full
recovery
rationale
Auxiliary Liver Transplant
Complete native liver
recovery
Immunusuppression Free
76%
DISIDA Scan 2 wks after
Tx
DISIDA Scan 1 Year post Tx
Biopsy at Tx
Biopsy at 1 year after Tx
Hepatocyte Tx For ALF
• Synthetic and detoxifying function for
few weeks
• No immunosuppression !
• Site that can be accessed in a
coagulopathic patient
Hepatocytes in Beads
Equipment Hood in Aseptic Room
Cannulation
“Mincing” Digested Tissue
Repeated Washing and Centrifugation
Checking Cell No. and Viability(Trypan Blue exclusion technique)
Hepatocyte Encapsulation
HCs/1.5% alginate
1.2% CaCl2
250µm nozzle
Reaction vessel
~400-450µm
CELL FUNCTION AND VIABILITY
MTT RESULTS OF MICROENCAPSULATED
HEPATOCYTES CULTURED IN WILLIAM'S E MEDIA
0
0.2
0.4
0.6
0.8
1
1.2
1.4
24Hrs 48Hrs 72Hrs 1 week
Av
era
ge
O.D
. a
t 6
30
nm
pe
r 1
00
mg
Be
ad
s
UREA PRODUCTION OF ENCAPSULATED HEPATOCYTES
CULTURED IN WILLIAM'S E MEDIA
0.0
0.2
0.4
0.6
0.8
1.0
24Hrs 48Hrs 72Hrs 1 Week
Ure
a c
on
ce
ntr
ati
on
(mg
/dL
) p
er
10
0m
g B
ea
ds
FACTOR VII PRODUCTION OF ENCAPSULATED
HEPATOCYTES CULTURED IN WILLIAM'S E MEDIA
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
24Hrs 48Hrs 72Hrs 1 Week
FV
II c
on
ce
ntr
ati
on
(n
g/m
l) p
er
10
0m
g B
ea
ds
Control 25% 50% 100%
Day 1
Day 7
Day 14
Viability Testing of Encapsulated Hepatocytes
Maintained in Ascitic Fluid
Culture medium only Culture medium + ascitic fluid
Cell Viability[Confocal Microscopy]
First in man Hepatocytes in Alginate beads for ALF March
2011
Microbeads
Before Tx
Retrieved
Microbeads
Albumin Production
[Post-retrieval]
0
100
200
300
400
D1 D7 D14
Days in culture
Alb
um
in (
ng
/mg
pro
tein
)
Watch for new etiologies !