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 !