Liver Disease in Cystic Fibrosis

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2 Liver Disease in Cystic Fibrosis Basic Overview Clinical Aspects Management

3 What Is Cystic Fibrosis? Autosomal recessive disease W-1:3000, H-1:10,000, AA-1:15,000 Mutations of CFTR defective Cl - transport CFTR Lung, pancreas, GI, sweat, bile ducts

4 What Is CF? Anatomy & Physiology 101 of CFTR MSD1 MSD2 Secretin camp Phosphorylation NBD1 ATP R NBD2 Channel OPENS ATP camp-pka-atp

5 What is CF? Anatomy & Physiology 101 of CF NBD1 MSD1 Secretin camp Phosphorylation NBD2 Channel OPENS R

6 What Is CF? Anatomy & Physiology 101 of CFTR Impaired CFTR RNA synthesis Defective folding and maturation F508 Abnormal regulation of Cl - conduction Inhibition of Cl - conduction Reduced synthesis of normal protein

7 What is CF? Anatomy & Physiology 101 of CFTR MSD1 Flow Viscosity Focal obstruction BAD bile acids NBD1 Liver cell injury Stellate cells R Fibrosis Secretion of Mucin Secretion UF Pediatric of Liver Mucin Center

8 Prevalence of Liver Disease in CF Retrospective Country No studied LFT Cirrhosis GB Sx HSM US 19, % % (1%) 0.3% UK 1, % 0.6% 4.2% UK % 25% France % 7% 0.8%

9 Prevalence of Liver Disease in CF Prospective Country No studied LFT Hepatomegaly US 99 38% US % Australia 153 9% 30% Italy % 30%

10 What Is the Clinical Presentation? Hepatomegaly Vertical span Xiphoid Portal HTN Cirrhosis Stigmata Abnormal LFT s Jaundice late Obstruction Reduced synthetic fxn Neonatal cholestasis Fatty liver Gallbladder

11 Can liver disease be predicted? Liver disease (%) Wilschanski, 1999 n=288 (liver dz: 80) Lung disease Weight Height Age 0 CFTR Pancreatic Gender Meconium Mec ileus Genotype Function (M/F) Ileus Equivalent

12 What Is the Natural History? Italian-prospective Follow-up Total studied yr Liver Disease 48 Cirrhosis yrs Portal HTN 13 Esophageal varices 4 Liver Transplant 1 Colombo et al Hepatology 2002

13 What is Natural History? Normal Ultrasound (n=106) Age 6 y/o F/U 10 yrs 6 scans/pt Normal (n=87) Hetero (n=15) 5 Hetero (n=5) Age Nodular Gender 1 Meconium (n=10) ileus-equiv Lung disease 4 Weight Height Nodular PHT (n=6) (n=8) Lenaerts et al. J Peds 2003

14 Evaluation of Liver Disease in CF History Liver-related issues Toxins Medications Alcohol Herbs and supplements Physical exam focus on liver

15 Evaluation of Liver Disease in CF Viral hepatitis: HAV, HBV, HCV Metabolic A1AT deficiency Wilson s Dz Hemochromatosis Autoimmune Drugs Hepatic congestion Heart failure Anatomical disorders Choledochal cysts Congenital hepatic fibrosis

16 Evaluation of Liver Disease in CF IDA Scan Endoscopy Specialized Testing ERCP Liver Bx

17 Management of Liver Disease in CF Screening!!! Liver size edge Liver biochemistry Medical Fatty liver: optimize nutrition Hepatic congestion Cholestasis-fibrosis-cirrhosis

18 Management of Liver Disease in CF Screening!!! Liver size edge Liver biochemistry Medical Fatty liver: optimize nutrition Hepatic congestion Cholestasis-fibrosis-cirrhosis

19 Management of Liver Disease in CF Cholestasis-fibrosis-cirrhosis Ursodeoxycholic acid Mechanisms of action Promotes HCO 3 -rich bile flow Displaces toxic bile acids Significantly retards fibrosis in PBC

20 Management of Liver Disease in CF Cholestasis-fibrosis-cirrhosis Colombo, children No 13.8 direct yrs evidence Liver delay disease or reversal Hepatomegaly of progressive LFT s fibrosis UDCA: 15 mg/kg/d x 1y UDCA Cirrhosis 11.2% to 3.2% No difference Portal HTN Esophageal varices GGT 5'nuc AST ALT

21 URSODEOXYCHOLIC ACID ARE THEY ALL ALIKE? William s Report AUC C max T max Urso250 Urso250 Ursolvan Actigall

22 Management of Liver Disease in CF Varices Endoscopic Beta-blockers Ascites Salt restriction Diuretics Portal hypertension Surgical Porto-systemic shunt Liver replacement

23 Management of Liver Disease in CF Liver Transplantation Pts Survival 1 yr 5 yrs Favorable lung fxn Mack, % 62% 5/5 Fridell, % 75% 8/9 UF Program, % 68% 6/8

24 Experimental Therapy for CF F508 4-phenyl butyrate Enhanced expression and Cl - secretion Restoration of Cl - transport

25 Liver Disease in Cystic Fibrosis Conclusions Important Medical Therapy Future

26 The Liver in Cystic Fibrosis Regino P. González-Peralta, M.D. Pediatric Hepatology and Liver Transplantation University of Florida College of Medicine Gainesville, Florida

27 Acknowledgements UF-Pediatric Pulmonary Axcan-Scandipharm Pharmaceuticals

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