Journal of Pediatric Gastroenterology and Nutrition 39:S611S615 June 2004 Lippincott Williams & Wilkins, Philadelphia

Cholestatic and Metabolic Liver Diseases: Working Group Report of the Second World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition
Richard J. Thompson (Coordinator), Ramiro Anthero Azevedo, Cristina Galoppo, Peter Lewindon, and Patrick McKiernan
From the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (R.J.T., P.M.); Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (R.A.A., C.G.); and Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition (P.L.).

Research 1. To understand the mechanisms of drug-induced cholestasis. 2. Which conditions are best treated by liver replacement therapy or bone marrow transplant, and how does one monitor the function of such cells? Intervention 1. To develop common diagnostic pathways for cholestatic or metabolic liver disease. 2. International network for rare diagnosis. 3. What are the minimal skills needed to care for biliary atresia. Education 1. Dissemination of practically useful research findings. 2. International framework for re-education.

Cholestatic and metabolic liver disease covers a wide range of conditions. At one end of the spectrum are rare genetic disorders and at the other are conditions such as biliary atresia. This report only addresses two research aspects directly. However, it suggests mechanisms for data collection and education. It is envisioned that these could easily be established worldwide and in turn would greatly aid all aspects of patient care and research. Although drug-induced cholestasis is relatively common, its many different forms mean that only a coordinated worldwide approach is likely to lead to rapid research progress. On the other hand, cell therapy techniques, such as hepatocyte transplantation, and bone marrow transplantation for metabolic liver disease are being performed in only a small number of centers. These centers do, however, represent great potential avenues. At the moment, we often lack the tools to know whether what we are doing works. This is therefore an important area for the future. The coordinated collection of research information, in a peer-reviewed fashion, is envisioned. This would feed many aspects of education and improve patient management. In a similar way, the minimum requirements involved in the planning of care for patients with biliary
Address correspondence and reprint requests to Dr. Thompson (e-mail: richard.j.thompson@kcl.uk).

atresia is envisioned that would aid healthcare providers and purchasers and ultimately the patients.

RESEARCH ISSUES Research Goal 1: To Understand the Mechanisms of Drug-Induced Cholestasis 1. Drug-induced cholestasis outwardly appears to be an idiosyncratic reaction to a particular environmental agent. As the mechanisms underlying bile formation and cholestasis are being unravelled, it will become possible to establish how and why it occurs (1). 2. Drug-induced cholestasis is a significant cause of liver-induced morbidity (2). 3. An understanding of the mechanisms of drug-induced liver injury would have several levels of benefit. For individuals, it might be possible to predict susceptibility and therefore avoid particular drugs or classes of drug. For physicians, a better understanding of drug-induced liver dysfunction would aid drug dosing and monitoring and improve the prediction of drug interactions. For the pharmaceutical industry, a better understanding of the causes of drug-induced liver damage could lead to in vitro models for drug testing. S611

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THOMPSON ET AL. 2. There has been a very rapid rise in our understanding of both metabolic and cholestatic liver disease. This has made possible a new range of diagnostic techniques, and it is often not clear what is, or should be, available. 3. It should be possible to establish a database of specialized investigations, including availability and costs. Intervention Goal 3: To Determine the Minimal Skills Needed to Care for Biliary Atresia Patients 1. The management of biliary atresia varies enormously, as do liver and patient survival rates. These factors could be improved if a minimum standard of care were available to all patients. 2. Biliary atresia remains the most common indication for liver transplantation in childhood and, as such, is a major problem (4). 3. A list of services and facilities deemed necessary for the long-term care of patients with biliary atresia should be produced. This will be of use during the development of service provision. EDUCATION ISSUES Education Goal 1: Dissemination of Practically Useful Research Findings 1. Current mechanisms for the dissemination of research information show considerable lag and are not always prioritized by utility. Mechanisms for overcoming this problem should be explored. 2. Research information is generally disseminated through presentations at meetings and subsequent publication. The dissemination of research information is essential for the improvement of patient care. The manifest publication bias for positive results means that important work is not published. This bias is detrimental to patient care. 3. The institution of a paper-free mechanism, with the support of all the affiliated organizations, for peerreviewed, noncommercial dissemination of research information is needed. Included would be positive and negative results as well as meta-analyses. Education Goal 2: International Framework for Re-education 1. A goal should be to develop a continuously changing dataset that represents the minimum expected skills and knowledge for specialists working in the field. 2. The maintenance of professional standards and standards for continuing education is organized differently around the world. However, particularly in rapidly changing areas of medicine, effective mecha-

Research Goal 2: To Determine Which Conditions Are Best Treated by Liver Replacement Therapy or Bone Marrow Transplantation, and How One Monitors the Function of Such Cells 1. Cell therapy is emerging as a treatment technique in several areas of medicine. The use of transplanted hepatocytes and/or bone marrow engraftment has been suggested as treatment for a variety of metabolic diseases (3). Which cell type or types are optimal for which disease is an area of interest in research. 2. Cell therapy has huge potential for the treatment of metabolic disease. It will become a useful treatment option in its own right. The use of allogeneic and autologous cells can be envisioned. The data collection proposed will also provide valuable information for the planning of gene therapy approaches. 3. For a variety of metabolic conditions, transplantation of both hepatocytes and bone marrowderived cells has already been attempted. It is clear that for some conditions, neither is likely to work because of the widespread nature of the defect. Equally, for some primary disorders of hepatic function, adequate treatment will require liver replacement therapy. For many conditions, however, it is known that a relatively small number of cells should be enough to correct the phenotype. A worldwide systematic approach to this should lead to a much quicker understanding of the potential for these forms of therapy, and to their limitations. INTERVENTION ISSUES Intervention Goal 1: To Develop Common Diagnostic Pathways for Cholestatic or Metabolic Liver Disease 1. To produce a pathway that would describe a rational route for the investigation of metabolic and cholestatic liver disease and permit the collection of common datasets for international collaboration. 2. Two problems exist. Firstly, some diseases are sufficiently rare that they risk being undiagnosed. Secondly, methods for making diagnoses evolve as new techniques emerge. 3. It should be possible to develop a pathway for the investigation of metabolic or cholestatic liver disease, based on the findings at presentation, that is practically useful and at the same time flexible enough to accommodate facilities available locally. Intervention Goal 2: To Establish an International Network for Rare Diagnoses 1. To establish a network of centers, around the world, capable to performing nonroutine investigations.

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CHOLESTATIC AND METABOLIC LIVER DISEASES nisms are needed for disseminating the minimum standards on a worldwide basis. 3. A model mechanism should be produced for the institution and maintenance of a rolling dataset for reeducation. The fields of cholestasis and metabolic liver disease will serve as a pilot. PLANS TO ACHIEVE GOALS Research Goal 1 This goal involves a coordinated approach to the investigation of drug-induced cholestasis. Although some drugs are well known for causing hepatic dysfunction, the total list of drugs that can cause such problems is huge. It seems very likely that, in most cases, the susceptibility that makes one person symptomatic, and not another, is genetically determined. The mechanisms involved in normal bile formation have in large part been unravelled in the last few years. This has been greatly aided by the study of patients with genetic forms of cholestasis. As a result of these studies, the molecular determinants of bile formation are now available. It is now possible to examine patients with acquired cholestasis (in this context, those with drug-induced cholestasis) for sequence changes in the genes encoding the major players in these processes. It is also possible to look at the function of most of the encoded proteins in vitro. So far, this has not been done for many sequence variants, only for the wild type normal sequence. It is now clear that these genes, like all others, are subject to polymorphic changes, the functional consequences of which would appear to be minimal under normal circumstances. However, most people are not exposed to many pharmacologic drugs. The proposed work would operate at several levels and would need coordinated help from many centers to achieve success. As most people are not exposed to many drugs, familial cases are rare. The only exception to this would be for relatively common drugs. In those cases in which there is familial exposure, linkage to particular genes could be explored. In all other cases, screening of whole genes for sequence variants is not realistic, but screening of known polymorphisms is quite possible. This screening would then require samples from large collections of such patients to achieve statistical significance. Without a very widespread coordinated approach, this is never going to be achieved. Furthermore, as the numbers of potential candidate genes grows, the number of centers involved in this work will likewise grow. Not all drugs are products of the pharmaceutical industry. In many parts of the world, herbal and other natural therapies are used. If sufficient numbers of patients were available, these would be included in the study. In vitro

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studies would be more difficult in this case, but valuable knowledge would be gained. Finally, once significant associations are found between sequence variants and cholestasis, these can be examined in vitro. This is likely to involve further centers doing such work. Pharmacogenetic approaches such as those suggested here have been attempted by various means. However, pediatric hepatologists collectively have access to a huge number of patients, which represent the means to answer these important questions. The eradication of druginduced cholestasis is an improbable aim for the near future, but it should become possible to predict which patients have particular risk. It should also be possible to identify sequence variants in key proteins that should be examined in vitro, to understand their function better; some of these sequence variants could be use for in vitro testing of novel compounds before any clinical trials. Not all cases of drug-induced hepatic dysfunction are primarily cholestatic. The planned work could be extended to look at more hepatic phenotypes in the future. Key mechanisms would be those involved in intermediate metabolism, which are often rate-limiting, such as the cytochrome p450s. Goal 2 Cell therapy is the subject of much discussion. Some metabolic diseases are obviously liver based, but even in the case of many of these, other cell types are actually involved in the disease. For other conditions, it is clear that many cell types are affected. The question for many conditions is not just which cells have a defect, but, more importantly, how many of which cell type are needed to achieve a clinically significant change of phenotype. This information is known for remarkably few conditions. There has been considerable discussion as to whether transdifferentiation can occurthat is, whether bone marrowderived stem cells, for instance, can differentiate into hepatocytes. For the purposes of this proposed body of work, this concept can be ignored, for several reasons. Firstly, where transdifferentiation has been identified, the numbers of cells have been very small. Furthermore, culturing large numbers of cells while maintaining pluripotentiality is proving to be extremely difficult. For the foreseeable future, large numbers of human stem cells can therefore be ignored. The question is more one of how many fully functioning, fully differentiated cells, in which organ, are needed to achieve an adequate correction of phenotype. Closely linked to this would be the question of how long the cells persisted. In simple terms, the presence of transplanted cells can be monitored in a number of ways. Most obviously, the clearance of a previously accumulated metabolite or the appearance of a previously unsynthesized metabolite can

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THOMPSON ET AL. topathologic, and genetic information. Important features would be whether the testing is still at a research stage, the established precision of the test, and the utility of the test (e.g., turn-around time for samples, cost). Goal 3 Biliary atresia remains the great enigma of pediatric hepatology. Recent initiatives in North America and separately in Europe are seeking to speed up research into both causes and treatments for biliary atresia. In parallel with this research, it should be possible to develop an international consensus on what facilities are necessary for the care of children with this condition. This should include all aspects, from initial management through monitoring, transplant options, and care of the patient as an adult. It is envisioned that this document would be of use to clinicians in the planning of services, in the negotiation of adequate funding, and to funding authorities in the purchase of healthcare provision. The result would be better, lifelong care for patients with biliary atresia. Education Goals 1 and 2 The mechanisms envisioned for both these goals might be quite similar. In many senses, they approach the same problem, but seen from different viewpoints. Goal 1 envisions an Internet-based searchable database into which research information could be placed. Ideally this might be independent of conventional publication, but for many reasons journal publication is unlikely to disappear in the near future. However, the need exists for a dataset that is not only peer-reviewed but also collected specifically to enable meta-analysis. Current metaanalysis is hampered by the bias toward positive results. In practice, the only negative results to get published are those of very large trials involving widely used treatments. Clearly, the data have to be collected properly and, as far as possible, in a uniform fashion. It is essential that this mechanism collects all data, whether the results are good or bad. If the information can be used to monitor outcome, such as in one unit versus another, there will be an inevitable bias in the same direction, as in publication. This dataset must therefore be capable of maintaining anonymity if necessary. An editorial board as well as expertise in metaanalysis would obviously be essential to maintain the dataset. In parallel, a tool for continuing re-education could be established. The output of meta-analyzed data will become the material on which best practice is based. Although the mechanisms of re-accreditation, or similar, vary enormously from country to country, the informa-

be looked for. Such a metabolite is most often found in the blood, though it could be found in urine, or, if available, in bile. Alternatively, for hematologic cells, an enzyme assay can be performed directly in the blood. In the liver, however, this would not only necessitate a biopsy but would also be subject to sampling error. The ideal monitoring system is one that is both sensitive and noninvasive. For most forms of treatment, an ideal system does not yet exist. Unfortunately, there is a built-in problem. For most diseases, we have developed sensitive tests to identify small amounts of unusual metabolites. At the same time, we are less good at looking for low levels of normal metabolites, which might be useful indicators of the function of transplanted cells. Although it may not always be possible to identify new metabolites for all diseases, it may become possible to administer a drug, the metabolite of which, or the clearance of which, is dependent on the function of the transplanted cells. The development of completely new assays, in this way, is going to be essential if these novel forms of treatment are going to succeed. To be successful, such as system will need close cooperation between hepatologists/transplant centers, metabolic physicians, and biochemists. It is anticipated that much of the development will come through the application of techniques such as tandem mass spectrometry to identify key markers of cell function. Importantly, similar monitoring techniques will be needed during gene therapy treatment. Interventions Goals 1 and 2 Many metabolic and cholestatic liver diseases are sufficiently rare that pediatricians who are called upon to look after children with these disorders will not see them frequently and may never have seen them before. Furthermore, even for conditions seen more often, advances in both molecular biology and analytical techniques mean that diagnostic opportunities are constantly changing. It is therefore proposed that two linked initiatives address this problem. Firstly, there should be a diagnostic pathway for metabolic and cholestatic liver diseases. This will obviously have to take into account local circumstances but could be easy to follow in a hypertext (html) format, using an Internet browser. A downloadable version should be available and, in this format, would be readable by most PDAs. The information contained in the database would be symptom-based. Closely linked to this should be goal 2, which would establish a network of laboratories involved in the diagnosis of such patients. This would obviously be disease-based. Goals 1 and 2 could be achieved within a single database, although it would obviously be interrogated in a different direction. The information on diagnostic tests would have to include analytical, enzymatic, immunologic, his-

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CHOLESTATIC AND METABOLIC LIVER DISEASES tion to be assimilated will be similar. Clearly, other aspects of professional practice require updating. But using a well-structured updated online learning tool will be an improvement on attending meetings. CONCLUSIONS Outlined in this working group report are a number of measures designed to facilitate research into two specific areas of cholestatic and metabolic liver disease. Druginduced cholestasis is relatively common but will require coordinated efforts from a large number of clinical and research centers if significant progress is to be made in its management. On the other hand, cell therapy has huge potential, but it is already clear that its implementation is not going to be simple. However, lessons can be learned that will be immensely useful for future treatments, such as gene therapy. Both educational and interventional aspects of this report are designed to improve the care of our patients, worldwide, through a number of initiatives, which are ultimately closely linked. A paper-free mechanism for peer-reviewed research information is needed; this should be comprehensive and include both positive and negative results. This will be built with the specific

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intention of aiding meta-analysis. The output from this exercise would be used to build a program for education and re-education that can be continually updated. The first two interventions would also gain from close linkage to the research information package described earlier. They will be aimed at producing a bedsidefriendly pathway to aid in the diagnosis of unusual cases and at the same time contain comprehensive, updated information on what diagnostic tests are available worldwide. Lastly, a project to suggest the requirements for the optimal management of biliary atresia, on a life-long basis, will be drawn up and used to facilitate better care at local and national levels. REFERENCES
1. Bramow S, Ott P, Thomsen Nielsen F, et al. Cholestasis and regulation of genes related to drug metabolism and biliary transport in rat liver following treatment with cyclosporine A and sirolimus (Rapamycin). Pharmacol Toxicol 2001;89:1339. 2. Levy C, Lindor KD. Drug-induced cholestasis. Clin Liver Dis 2003;7:31130. 3. Fox IJ, Chowdhury JR. Hepatocyte transplantation. Am J Transplant 2004;4(Suppl 6):713. 4. McKiernan PJ, Baker AJ, Kelly DA. The frequency and outcome of biliary atresia in the UK and Ireland. Lancet 2000;355:259.

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