Crigler-Najjar syndrome Research Papers - Academia.edu (original) (raw)

Children with Crigler-Najjar syndrome type I are at increased risk for neurologic deficits. Cerebellar symptoms are not prominent and appear in adolescent or adult patients with this syndrome. We report a 2-yearold female with Crigler-Najjar syndrome type I who presented severe cerebellar symptoms revealing bilirubin encephalopathy. The patient improved slowly with the duration of phototherapy. Cerebellar symptoms can be the initial manifestation of kernicterus in children with Crigler-Najjar syndrome type I.

- by
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- Magnetic Resonance Imaging, Pediatric Neurology, Brain, Cerebellum

Objective: To report a case of maternal Crigler-Najjar syndrome (CNS) type II in pregnancy, systematically review the literature for similar case reports, and to evaluate whether pregnancy is safe in patients with the disease. Data sources included the PubMed and uptodate databases. Results: A 37-year-old mother with CNS type II was treated with phenobarbital during her pregnancy and her bilirubin levels were monitored. Her newborn had mild direct hyperbilirubinemia, did not require any treatment and his postnatal followup showed normal growth and development as well as normal hearing. Conclusion: CNS type II is rare, and only a few pregnancies with this condition have been reported. Maternal treatment with phenobarbital lowers the unconjugated bilirubin and avoids fetal and newborn sequelae.

- by Christine Skala and +1
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- Pregnancy, Case Report, Hearing disorders, Growth and development

The Crigler-Najjar Syndrome Type I (CNSI) is a rare genetic disorder caused by mutations in the Ugt1a1 gene. It is characterized by unconjugated hyperbilirubinemia that may result in severe neurologic damage and death if untreated. To date, liver transplantation is the only curative treatment. With the aim of generating mutant cell lines of the Ugt1 gene, we utilized the TALEN technology to introduce site-specific mutations in Ugt1 exon 4. We report a fast and efficient method to perform gene knockout in tissue culture cells, based on the use of TALEN pairs targeting restriction enzyme (RE) sites in the region of interest. This strategy overcame the presence of allele-specific single nucleotide polymorphisms (SNPs) and pseudogenes, conditions that limit INDELs' detection by Surveyor. We obtained liver-derived murine N-Muli cell clones having INDELs with efficiency close to 40%, depending on the TALEN pair and RE target site. Sequencing of the target locus and WB analysis of the ...

- by Andres Muro
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- Engineering, Physics, Chemistry, Genomics
- by Satinder Aneja and +1
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- Mutation, Infant, Jaundice, Crigler-Najjar syndrome
- by may chehab
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- Saudi Arabia, Child, Clinical, Infant

Symptoms usually subside over a week and infarcted appendages transform into a fibrotic or a calcified mass, but it may detach from the serosa and become a mobile mass in the pelvic area (5). If left untreated, peritonitis and intestinal... more

- by Aynur Yilmaz
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- Emergency Medicine, Urology, Acute kidney injury, Acute renal failure

Crigler-Najjar (CN) disease is classified into two subtypes, type I and II. The molecular basis for the difference between these types is not well understood.

- by Piter Bosma
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- Adolescent, Child, Mutation, Clinical

Four children underwent living related liver transplantation because of Crigler-Najjar syndrome type 1. Three were infants aged 2, 8 1 ⁄2, and 15 months, and weighed 5, 8, and 10 kg, respectively. Pretransplantation unconjugated bilirubin concentration was 22 to 30 mg/dL despite 12 to 14 hours of phototherapy daily. Patient 1, the 2-month-old infant, with unconjugated bilirubin concentration of 30 mg/dL, had a high-pitched cry, suggestive of bilirubin encephalopathy; results of neurologic examination were normal. Plasmapheresis and urgent liver transplantation were performed. Patient 4, a 13-year-old girl, had learning difficulties at school and attended a special class. Three patients received left lateral liver segments, and 1 patient received a left lobe. Biliary reconstruction was completed with duct-to-duct anastomosis. Bile leakage developed at the anastomosis in 2 patients, which was treated successfully with cholangioplasty. In all patients, the unconjugated bilirubin concentration normalized by day 1 posttransplantation, and no phototherapy was necessary. After transplantation, the 2-month-old infant with suspected encephalopathy exhibited hypotonia, spasticity of the lower extremities, and lack of head control. He died after vomitus aspiration during sleep at 10 months posttransplantation. The other 3 patients are alive with normal neurodevelopmental milestones. Irreversible brain damage may occur early in the course of Crigler-Najjar syndrome type 1. Urgent treatment including plasmapheresis, exchange transfusion, phototherapy, and liver transplantation may not reverse brain damage. Young infants must be evaluated carefully for subtle signs and symptoms of bilirubin encephalopathy. Liver transplantation is curative if performed before development of neurologic dysfunction.

- by Gokhan Moray
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- Family, Learning Difficulties, Adolescent, Infant

Crigler-Najjar syndrome type I is a rare inborn error of bilirubin metabolism due to a deficiency of the hepatic microsomal bilirubin uridine diphosphate-glucuronosyltransferase (B-UDPGT) enzyme. To reduce the risk of life threatening kernicterus, patients undergo daily session of phototherapy. The only therapeutic alternatives are liver or hepatocyte transplantation but significant risks and costs are associated with these procedures. Since all other pathways for bilirubin metabolism are functional in the patients, gene therapy may represent an alternative treatment. An excellent model of this disease exists in the Gunn rat. Previously, partial correction of hyperbilirubinemia in Gunn rats for up to 4 weeks was reported using E1-deleted adenoviral (Ad) vectors; however, the therapeutic index of E1-deleted Ad is limited due to strong host immune response to the viral proteins, acute toxicity and short duration of expression. Helper-dependent adenoviral (HD-Ad) vectors, devoid of all viral coding sequences, have a safer chronic toxicity profile compared with early generation Ad vectors and allow for long-term transgene expression. We used HD-Ad vectors and tissue-restricted expression of human B-UDPGT in Gunn rats. Complete correction of hyperbilirubinemia was achieved after a single systemic administration of 3 x 1012 viral particles/kg of HD-Ad vectors expressing human B-UDPGT under the control of the rat phosphoenolpyruvate carboxylase (PEPCK) promoter into Gunn rats. Total bilirubin levels in the plasma were stably reduced from above 7.0 mg/dL to less than 1.0 mg/dL for at least 7 months. Specific hepatic expression of human B-UDPGT was confirmed by RNA and protein analysis in liver biopsy from animals sacrificed 20 weeks post-injection. A clinically significant reduction in total bilirubin levels was observed with a dose as low as 6 x 1011 viral particles/kg. No significant increase in liver enzymes was detected at a dose as high as 1 x 1013 viral particles/kg. Transient, dose-related thrombocytopenia developed after systemic injection of the vector at higher doses and resolved in 3 weeks. We conclude that complete, long-term correction of hyperbilirubinemia may be achieved by a single HD-Ad adenoviral administration in the animal model of Crigler-Najjar syndrome type I with negligible chronic toxicity.

- by Gabriele Toietta
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- Gene Therapy, Bilirubin, Adenoviral vectors, Crigler-Najjar syndrome

- by F. Alehan
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- Family, Learning Difficulties, Adolescent, Infant
- by Sanjiv Saigal
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- Surgery, Decision Making, Gastroenterology, Survival Analysis

Adeno-associated virus serotype 8 (AAV8) has been demonstrated to be effective for liver-directed gene therapy in humans. Although hepatocytes are the main target cell for AAV8, there is a loss of the viral vector because of uptake by macrophages and Kupffer cells. Reducing this loss would increase the efficacy of viral gene therapy and allow a dose reduction. The receptor mediating this uptake has not been identified; a potential candidate seems the macrophage scavenger receptor A (SR-A) that is involved in the endocytosis of, for instance, adenovirus. In this study we show that SR-A can mediate scAAV8 endocytosis and that blocking it with polyinosinic acid (poly[i]) reduces endocytosis significantly in vitro. Subsequently, we demonstrate that blocking this receptor improves scAAV-mediated liver-directed gene therapy in a model for inherited hyperbilirubinemia, the uridine diphospho-glucuronyl transferase 1A1-deficient Gunn rat. In male rats, preadministration of poly [i] increases the efficacy of a low dose (1 · 10 11 gc/kg) but not of a higher dose (3 · 10 11 gc/kg) scAAV8-LP1-UT1A1. Administration of poly[i] just before the vector significantly increases the correction of serum bilirubin in female rats. In these, the effect of poly[i] is seen by both doses but is more pronounced in the females receiving the low vector, where it also results in a significant increase of bilirubin glucuronides in bile. In conclusion, this study shows that SR-A mediates the endocytosis of AAV8 in vitro and in vivo and that blocking this receptor can improve the efficacy of AAV-mediated liver-directed gene therapy.

- by Piter Bosma
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- Cell line, Liver, Medical Biotechnology, Endocytosis

We summarize the treatment of 20 patients with Crigler-Najjar disease (CND) managed at one center from 1989 to 2005 (200 patient-years). Diagnosis was confirmed by sequencing the UGTA1A gene. Nineteen patients had a severe (type 1) phenotype. Major treatment goals were to maintain the bilirubin to albumin concentration ratio at <0.5 in neonates and <0.7 in older children and adults, to avoid drugs known to displace bilirubin from albumin, and to manage temporary exacerbations of hyperbilirubinemia caused by illness or gallstones. A variety of phototherapy systems provided high irradiance over a large body surface. Mean total bilirubin for the group was 16±5 mg/dl and increased with age by approximately 0.8 mg/dl per year. The molar ratio of bilirubin to albumin ranged from 0.17 to 0.75 (mean: 0.44). The overall non-surgical hospitalization rate was 0.12 hospitalizations per patient per year; one-half of these were for neonatal hyperbilirubinemia and the remainder were for infectious illnesses. Ten patients (50%) underwent elective laproscopic cholecystectomy for cholelithiasis. No patient required invasive bilirubin removal or developed bilirubin-induced neurological damage under our care. Visual acuity and color discrimination did not differ between CND patients and age-matched sibling controls.

- by Graham J Hart
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- Adolescent, Phototherapy, Visual acuity, Child

- by Paolo Setti Carraro
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- Technology, Biological Sciences, Child, Cell
- by Elísio Costa
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- Polymorphism, Adolescent, Portugal, Child

Crigler-Najjar syndrome types I and II (CN1 and CN2) are usually inherited as autosomal recessive conditions and are characterized by non-hemolytic unconjugated hyperbilirubinaemia. CN1 is the most severe form, associated with the absence of hepatic bilirubin-uridinediphosphoglucuronate glucuronosyltransferase (UGT1A1) activity. CN2 presents intermediate levels of hyperbilirubinaemia as a result of an incomplete deficiency of hepatic UGT1A1 activity. Here, we present the analysis of UGT1A1 gene in 31 unrelated Crigler-Najjar (CN) syndrome patients. This analysis allowed us to identify 22 mutations, 12 of which were no previously described, expanding the spectrum of known UGT1 mutations to 77. Novel mutations, considered pathogenic, including one nonsense mutation, two altered splice sites, one single base deletion and nine missense mutations were identified in coding exons of the UGT1A1 gene and flanking introns. Several novel missense mutations localize in critical domain of UGT1A1 enzyme. In addition, the evaluation of Gilbert-type promoter of UGT1A1 in Crigler-Najjar (CN) syndrome patients was performed. The polymorphisms of the promoter region can modify the UGT1A1 mutation phenotype. This study represents the molecular characterization of the largest cohort of Italian Crigler-Najjar Gilbert syndrome patients studied so far; increase the mutational spectrum of UGT1A1 allelic variants worldwide and provide a new insight useful for clinical diagnosis and genetic counseling.

- by F. Ronchi
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- Genetics, Morocco, Human, Italy

- by D. Morton and +2
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- Adolescent, Phototherapy, Visual acuity, Child

Crigler-Najjar (CN) disease is classified into two subtypes, type I and II. The molecular basis for the difference between these types is not well understood. Several mutations in the bilirubin UDP-glucuronosyltransferase (B-UGT) gene of six CN type I and two CN type II patients were identified. Recombinant cDNAs containing these mutations were expressed in COS cells. B-UGT activity was measured using HPLC and the amount of expressed protein was quantitated using a sandwich ELISA. This enabled us to determine the specific activities of the expressed enzymes. All type I patients examined had mutations in the B-UGT1 gene that lead to completely inactive enzymes. The mutations in the B-UGT1 gene of patients with CN type II only partially inactivated the enzyme. At saturating concentrations of bilirubin (75 IAM) CN type II patient A had 4.4±2% residual activity and CN type II patient B had 38+2% residual activity. Kinetic constants for the glucuronidation of bilirubin were determined. The affinities for bilirubin of B-UGT1 expressed in COS cells and B-UGT from human liver microsomes were similar with Km of 5.1±0.9 ,uM and 7.9±5.3 ,uM, respectively. B-UGT1 from patient B had a tenfold decreased affinity for bilirubin, Km = 56±23 ,LM. At physiological concentrations of bilirubin both type II patients will have a strongly reduced conjugation capacity, whereas type I patients have no B-UGT activity. We conclude that CN type I is caused by a complete absence of functional B-UGT and that in CN type II B-UGT activity is reduced.

- by Ronald Elferink
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- Adolescent, Child, Mutation, Clinical
- by Robert Mooney
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- Adolescent, Child, Infant, Bilirubin

- by Jayanta Roy-Chowdhury
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- Adolescent, Child, Mutation, Clinical
- by Piter Bosma
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- Genetics, Biological Sciences, Liver, Mutation
- by James Littlewood
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- Phototherapy, Follow-up studies, Bilirubin, Clinical Sciences
- by Jayanta Roy-Chowdhury
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- Catalysis, Biological Chemistry, Biological Sciences, Cell line

Increased levels of unconjugated bilirubin are neurotoxic, but the mechanism leading to neurological damage has not been completely elucidated. Innovative strategies of investigation are needed to more precisely define this pathological process. By longitudinal in vivo bioluminescence imaging, we noninvasively visualized the brain response to hyperbilirubinemia in the MITO-Luc mouse, in which light emission is restricted to the regions of active cell proliferation. We assessed that acute hyperbilirubinemia promotes bioluminescence in the brain region, indicating an increment in the cell proliferation rate. Immunohistochemical detection in brain sections of cells positive for both luciferase and the microglial marker allograft inflammatory factor 1 suggests proliferation of microglial cells. In addition, we demonstrated that brain induction of bioluminescence was altered by pharmacological displacement of bilirubin from its albumin binding sites and by modulation of the blood–brain barrier permeability, all pivotal factors in the development of bilirubin-induced neurologic dysfunction. We also determined that treatment with minocycline, an antibiotic with anti-inflammatory and neuroprotective properties, or administration of bevacizumab, an anti-vascular endothelial growth factor antibody, blunts bilirubin-induced bioluminescence. Overall the study supports the use of the MITO-Luc mouse as a valuable tool for the rapid response monitoring of drugs aiming at preventing acute bilirubin-induced neurological dysfunction.

- by Gabriele Toietta
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- Molecular Imaging, Brain, Blood brain barrier, Microglia
- by Elísio Costa
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- Genetics, Mutation, Clinical Sciences, Crigler-Najjar syndrome

- by Flavio Ronchi
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- Genetics, Morocco, Human, Italy

Crigler-Najjar syndrome type 1 (CN-1) is characterized by severe unconjugated hyperbilirubinemia due to an inherited deficiency of hepatic bilirubin uridinediphosphoglucuronate glucuronosyltransferase (UGT1A1), inherited as an autosomal recessive characteristic. CN-1 is potentially lethal because of the risk of bilirubin encephalopathy (kernicterus). Genetic lesions of the coding region of the UGT1A1 gene are known to cause CN-1. Here, we report a CN-1 patient who has a novel G > A mutation at the splice acceptor site in intron 4 (IVS4-1 G > A) on one allele, and a T > A substitution followed by a 13-nt deletion in exon 2 (877T > A 878 -890del) of the other allele. As the UGT1A1 gene is expressed specifically in the liver, structural analysis of the expressed UGT1A1 mRNA requires liver biopsy. To use a noninvasive approach to determine the effect of the splice site mutation on splicing of the RNA transcript, we amplified the relevant region of the genomic DNA by long-range polymerase chain reaction (PCR). The amplicon was cloned in an expression plasmid and transfected into COS-7 cells. The expressed mRNA was amplified by reverse-transcription-primed PCR. Nucleotide sequence determination of the amplicon showed that the splice acceptor site mutation caused splicing of the 3-end of exon 4 to a cryptic splice site within exon 5. This resulted in deletion of the first 7 nucleotides of exon 5, causing a frameshift and premature truncation of UGT1A1, with consequent inactivation of the enzyme. © 2002 Elsevier Science (USA)

- by Jayanta Roy-Chowdhury
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- Genetics, Molecular Genetics, Mutation, Polymerase Chain Reaction

Crigler-Najjar type I (CNI) syndrome is a recessively inherited disorder characterized by severe unconjugated hyperbilirubinemia caused by uridine diphosphoglucuronosyltransferase 1A1 (UGT1A1) deficiency. The disease is lethal due to bilirubin-induced neurological damage unless phototherapy is applied from birth. However, treatment becomes less effective during growth, and liver transplantation is required. To investigate the pathophysiology of the disease and therapeutic approaches in mice, we generated a mouse model by introducing a premature stop codon in the UGT1a1 gene, which results in an inactive enzyme. Homozygous mutant mice developed severe jaundice soon after birth and died within 11 d, showing significant cerebellar alterations. To rescue neonatal lethality, newborns were injected with a single dose of adeno-associated viral vector 9 (AAV9) expressing the human UGT1A1. Gene therapy treatment completely rescued all AAV-treated mutant mice, accompanied by lower plasma bilirubin levels and normal brain histology and motor coordination. Our mouse model of CNI reproduces genetic and phenotypic features of the human disease. We have shown, for the first time, the full recovery of the lethal effects of neonatal hyperbilirubinemia. We believe that, besides gene-addition-based therapies, our mice could represent a very useful model to develop and test novel technologies based on gene correction by homologous recombination.-Bortolussi, G., Zentilin, L., Baj, G., Giraudi, P., Bellarosa, C., Giacca, M., Tiribelli, C., Muro, A. F. Rescue of bilirubin-induced neonatal lethality in a mouse model of Crigler-Najjar syndrome type I by AAV9-mediated gene transfer. FASEB J. 26, 1052-1063 (2012). www.fasebj.org

- by Gabriele Baj
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- Physiology, Skeletal muscle biology, Western blotting, Cerebellum

which reliable administration of phototherapy cannot This study represents a multicenter survey on the be guaranteed. (HEPATOLOGY 1996;24:311-315.) management of patients with Crigler-Najjar syndrome (CNS) type 1. The aim of the survey was to find guiding principles for physicians in the care of these patients. Fifty-seven patients were included. At the time of inclu-Crigler-Najjar syndrome (CNS) is characterized by unconsion, 21 patients had received a liver transplant (37%). jugated hyperbilirubinemia since birth. 1 CNS type 1 results The average age at transplantation was 9.1 { 6.9 years from a complete deficiency of the enzyme bilirubin UDP-(range, 1-23 years); the age of the patients who had not glucuronosyltransferase (UGT), and CNS type 2 results from been transplanted at the time of inclusion was 6.9 { 6.0 a partial deficiency. Bilirubin UGT is a member of the UGT years (range, 0-23 years). Brain damage had developed family, a group of enzymes encoded by the UGT1 and UGT2 in 15 patients (26%). Five patients died, and 10 are alive genes on human chromosomes 2 and 4. UGTs are located in with some degree of mental or physical handicap. In 2 the endoplasmic reticulum of the hepatocyte. UGT isoforms patients, ages 22 and 23 years, early signs of bilirubin are present in various other organs such as intestine, kidney, encephalopathy could be reversed, in 1 by prompt medilungs, and adrenals. 2 cal intervention followed by liver transplantation and CNS occurs with an estimated frequency of about 0.6 per in the other by prompt liver transplantation. Seven pamillion; for example, in the Netherlands, there are nine type tients underwent transplantation with some degree of 1 patients in a population of 15.5 million. Approximately 70 brain damage at the time of the surgery; 1 of these died cases have been reported in the literature thus far. 3-5 The after retransplantation, 2 improved neurologically, and first report was in 1952 by Crigler and Najjar. 1 Before the 4 remained neurologically impaired. The age of 8 paadvent of phototherapy, the disease was lethal, with death tients with and 13 without brain damage at or before occurring by the age of 15 months. transplantation was 14.3 { 5.9 and 5.9 { 5.4 years (P In CNS type 1, serum bilirubin values of untreated patients õ .01), respectively. Therapy of CNS type 1 consists of are in excess of 350 mmol/L, and bile contains not more than phototherapy (12 h/d), followed by liver transplantation. traces of bilirubin conjugates. 6,7 Kernicterus is a complication Phototherapy, although initially very effective, is sothat can also develop later in life. CNS type 2 is less secially inconvenient and becomes less efficient in the vere, with serum bilirubin values usually not exceeding 350 older age group, thus also decreasing compliance. Curmmol/L. The bile of these patients contains bilirubin monorently, liver transplantation is the only effective therand diglucuronides in low concentration. 6,7 Their serum biliapy. This survey shows that, in a significant number of rubin responds to phenobarbital treatment with a decrease patients, liver transplantation is performed after some by 30% or more. 10 Genetically, both diseases result from muform of brain damage has already occurred. From this, tations in the exons of the UGT1 gene. 2 CNS types 1 and one must conclude that liver transplantation should be 2 are autosomal recessive diseases because both alleles are performed at a young age, particularly in situations in affected. 11-17 Patients with one normal allele have a normal bilirubin metabolism. 2 Treatment of CNS type 1 consists of exchange transfusions after birth and phototherapy, usually 12 hours per day, for many years. 18 Liver transplantation is Abbreviations: CNS, Crigler-Najjar syndrome; UGT, UDP-glucuronosyltransferase. From the type 1. A questionnaire was sent to responding physicians. The fol- § Dr. van der Veere was supported by a grant from the Crigler-Najjar Foundation, The lowing information was requested:

- by Peter Jansen
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- Adolescent, Hepatology, Phototherapy, Child

Crigler-Najjar syndrome is a recessively inherited disorder characterized by severe unconjugated hyperbilirubinemia caused by a deficiency of uridine diphospho-glucuronosyl transferase 1A1. Current therapy relies on phototherapy to prevent kernicterus, but liver transplantation presently is the only permanent cure. Gene therapy is a potential alternative, and recent work has shown that helper-dependent adenoviral (HD-Ad) vectors, devoid of all viral coding sequences, induce prolonged transgene expression and exhibit significantly less chronic toxicity than early-generation Ad vectors. We used a HD-Ad vector to achieve liver-restricted expression of human uridine diphospho-glucuronosyl transferase 1A1 in the Gunn rat, a model of the human disorder. Total plasma bilirubin levels were reduced from >5.0 mg/dl to <<1.4 mg/dl for >2 yr after a single i.v. administration of vector expressing the therapeutic transgene at a dose of 3 x 10(12) viral particles per kg. HPLC analysis of bile from treated rats showed the presence of bilirubin glucuronides at normal WT levels >2 yr after one injection of vector, and i.v. injection of bilirubins IIIalpha and XIIIalpha in the same animals revealed excess bilirubin-conjugating capacity. There was no significant elevation of liver enzymes (alanine aminotransferase) and only transient, moderate thrombocytopenia after injection of the vector. A clinically significant reduction in serum bilirubin was observed with a dose as low as 6 x 10(11) viral particles per kg. We conclude that complete, long-term correction of hyperbilirubinemia in the Gunn rat model of Crigler-Najjar syndrome can be achieved with one injection of HD-Ad vector and negligible chronic toxicity.

- by Gabriele Toietta
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- Gene Therapy, Liver diseases, Liver, Jaundice

Liver cell transplantation is an attractive technique to treat liver-based inborn errors of metabolism. The feasibility and efficacy of the procedure has been demonstrated, leading to medium term partial metabolic control of various diseases. Crigler-Najjar is the paradigm of such diseases in that the host liver is lacking one function with an otherwise normal parenchyma. The patient is at permanent risk for irreversible brain damage. The goal of liver cell transplantation is to reduce serum bilirubin levels within safe limits and to alleviate phototherapy requirements to improve quality of life. Preliminary data on Gunn rats, the rodent model of the disease, were encouraging and have led to successful clinical trials. Herein we report on two additional patients and describe the current limits of the technique in terms of durability of the response as compared to alternative therapeutic procedures. We discuss the future developments of the technique and new emerging perspectives.

- by Françoise Smets
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- Clinical Trial, Quality of life, Treatment Outcome, Cell therapy

Patients with Crigler-Naijar syndrome (CN) type I inherit an autosomal recessive trait for hyperbilirubinemia, which is characterized by the total absence of bilirubin UDP-glucuronosyltransferase (transferase) activity. The recent... more

- by patrick ferreira
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- Genetics, Mutation, Clinical, Crigler-Najjar syndrome

Crigler-Najjar syndrome (CNS) type I and type II are inherited as autosomal recessive conditions that are caused by mutations in the UGT1A1 gene. We present the analysis of UGT1A1 gene in 12 individuals from three different families. This analysis allowed us to identify one novel mutation, which was not previously described. In this study, three families with clinically diagnosed CNS referred from Khuzestan province, southwest Iran, were screened. After signing the informed consent, peripheral blood samples from the patients and their parents were collected in EDTA-containing tube followed by DNA extraction using a routine phenol-chloroform method. All five coding exons and the flanking intronic regions of the bilirubin-UGT were amplified by polymerase chain reaction (PCR) followed by DNA sequencing by Sanger method. From the first family, a 9-month-old boy was homozygous for a deletion mutation of two adjacent nucleotides including one adenosine (A) and one glutamine (G) between nu...

- by Mohammad Masbi
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- Iran, Child, Mutation, Infant
- by Sigismondo Castaldo
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- Treatment Outcome, Liver, Rats, Crigler-Najjar syndrome

Crigler-Najjar syndrome type 1 (CN1) is an inherited disorder characterized by the absence of hepatic uridine diphosphoglucuronate glucuronosyltransferase (UDPGT), the enzyme responsible for the conjugation and excretion of bilirubin. We performed allogenic hepatocyte transplantation (AHT) in a child with CN1, aiming to improve bilirubin glucuronidation in this condition. A 9-year-old boy with CN1 was prepared with plasmapheresis and immunosuppression with prednisolone and tacrolimus. When a graft was made available, 7.5 × 109 hepatocytes were isolated and infused into the portal vein percutaneously. After 2 weeks phenobarbitone was added to promote the enzymatic activity of UDPGT of the transplanted hepatocytes. Nocturnal phototherapy was continued throughout the studied period. Total bilirubin was considered a reliable marker of allogenic cell function. There was no significant variation of vital signs nor complications during the infusion. Mean ± SD bilirubin level was 530 ± 38 μ...

- by Lorenzo D'Antiga
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- Technology, Biological Sciences, Child, Cell

Liver cell transplantation in humans has been impeded by invariable loss of the graft. It is unclear whether graft loss is due to an immune response against donor hepatocytes. Transplantation with ABO-matched liver cells was performed in a patient with Crigler-Najjar type 1. After successful engraftment, there was a gradual loss of graft function. Solid-phase enzyme immunoassay testing and cell-complement cytotoxicity assays detecting preformed antibodies directed toward class I and/or class II human leukocyte antigen (HLA) molecules were negative. In contrast, a striking host alloresponse to either the HLA-B39 or C7 antigen was found, suggesting that a vigorous response to a defined mismatched HLA antigen contributed to graft loss in our patient. This study provides evidence that a T-cell–mediated immune mechanism could be responsible for human liver cell transplant graft loss. This finding warrants confirmation in future liver cell transplants in humans. Liver Transpl 14:688–694, 2008. © 2008 AASLD.

- by Katrina Allen
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- Child, Liver, Liver Transplantation, Cell Transplantation

Liver cell transplantation in humans has been impeded by invariable loss of the graft. It is unclear whether graft loss is due to an immune response against donor hepatocytes. Transplantation with ABO-matched liver cells was performed in a patient with Crigler-Najjar type 1. After successful engraftment, there was a gradual loss of graft function. Solid-phase enzyme immunoassay testing and cell-complement cytotoxicity assays detecting preformed antibodies directed toward class I and/or class II human leukocyte antigen (HLA) molecules were negative. In contrast, a striking host alloresponse to either the HLA-B39 or C7 antigen was found, suggesting that a vigorous response to a defined mismatched HLA antigen contributed to graft loss in our patient. This study provides evidence that a T-cell-mediated immune mechanism could be responsible for human liver cell transplant graft loss. This finding warrants confirmation in future liver cell transplants in humans. Liver Transpl 14: 688-694, 2008.

- by Patrick Bertolino
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- Child, Liver, Liver Transplantation, Cell Transplantation

- by Figen Ozcay
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- Family, Learning Difficulties, Adolescent, Infant

Background. In living donor liver transplantation (LDLT), the liver donor is almost always a blood relative; therefore, the donor is sometimes a heterozygous carrier of inheritable diseases. The use of such carriers as donors has not been validated. The aim of the present study was to evaluate the outcome of LDLT for noncirrhotic inheritable metabolic liver disease (NCIMLD) to clarify the effects of using a heterozygous carrier as a donor. Methods. Between June 1990 and December 2003, 21 patients with NCIMLD underwent LDLT at our institution. The indications for LDLT included type II citrullinemia (n ϭ 7), ornithine transcarbamylase deficiency (n ϭ 6), propionic acidemia (n ϭ 3), Crigler-Najjar syndrome type I (n ϭ 2), methylmalonic acidemia (n ϭ 2), and familial amyloid polyneuropathy (n ϭ 1). Of these 21 recipients, six underwent auxiliary partial orthotopic liver transplantation. Results. The cumulative survival rate of the recipients was 85.7% at both 1 and 5 years after operation. All surviving recipients are currently doing well without sequelae of the original diseases, including neurological impairments or physical growth retardation. Twelve of the 21 donors were considered to be heterozygous carriers based on the modes of inheritance of the recipients' diseases and preoperative donor medical examinations. All donors were uneventfully discharged from the hospital and have been doing well since discharge. No mortality or morbidity related to the use of heterozygous donors was observed in donors or recipients.

- by Daisuke Morioka
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- Treatment Outcome, Adolescent, Liver diseases, Transplantation

Crigler-Najjar Syndrome (CNS) is characterized by mild, chronic unconjugated hyperbilirubinemia resulting from an autosomal-recessive inherited deficiency of hepatic uridine/ diphosphoglucuronate-glucuronosyl transferace 1Al since birth. Herein we have reported a confirmed case of CNS type 1 in a 2-year-old girl with an unconjugated hyperbilirubinemia (Ͼ30 mg/dL) treated by hepatic progenitor cell infusion through the hepatic artery. No procedure-related complications were encountered. No kernicterus was observed. The total bilirubin started falling at 10 days after cell infusion. Two months after cell infusion the bilirubin fell from 29.0 to 16 mg/dL, with the conjugated bilirubin increasing approximately fivefold, the unconjugated bilirubin decreasing nearly twofold, and the SGPT also decreasing from 210 U/L to 64 U/L. This study demonstrated the efficacy of hepatic progenitor cells to manage hyperbilirubinemia in these patients. As the procedure is simple and the patient has tolerated the cell therapy, infusion can be repeated as required to manage hyperbilirubinemia, which often causes lethal kernicterus. This study was developed to assess the safety, feasibility, and efficacy of hepatic progenitor cell transplantation in a child with CNS type 1.

- by Parveen Nyamath
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- Stem Cell Transplantation, Cell therapy, Polymerase Chain Reaction, Bilirubin
- by Jayanta Roy-Chowdhury
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- Genetics, Gene Therapy, Gene transfer techniques, Viruses

Crigler-Najjar (CN) disease is classified into two subtypes, type I and II. The molecular basis for the difference between these types is not well understood.

- by Piter Bosma
- •
- Adolescent, Child, Mutation, Clinical

Crigler-Najjar (CN) disease is classified into two subtypes, type I and II. The molecular basis for the difference between these types is not well understood.

- by Piter Bosma
- •
- Adolescent, Child, Mutation, Clinical
- by Cindy Kunne
- •
- Immune response, Gene Therapy, Gene expression, Biological Sciences
- by Cindy Kunne
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- Immune response, Gene Therapy, Gene expression, Biological Sciences
- by Peter Jansen
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- Genetics, Lancet, Crigler-Najjar syndrome
- by Séverine Remy
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- Gastroenterology, Antibodies, Liver, Polymerase Chain Reaction
- by Emília Vieira
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- Genetics, Human Genetics, Complementary and Alternative Medicine, Peptides

As recently demonstrated in patients with factor IX deficiency, adeno-associated virus (AAV)-mediated liverdirected therapy is a viable option for inherited metabolic liver disorders. Our aim is to treat Crigler-Najjar syndrome type I (CN I), an inherited severe unconjugated hyperbilirubinemia, as a rare recessive inherited disorder. Because the number of patients eligible for this approach is small, the efficacy can only be demonstrated by a beneficial effect on the pathophysiology in individual patients. Serum bilirubin levels in potential candidates have been monitored since birth, providing an indication of their pathophysiology. Adjuvant phototherapy to prevent brain damage reduces serum unconjugated bilirubin (UCB) levels in CN I patients to the level seen in the milder form of the disease, CN type II. This therapy increases the excretion of UCB, thereby complicating the use of UCB and conjugated bilirubin levels in serum as biomarkers for the gene therapy we try to develop. Therefore, a suitable biomarker that is not affected by phototherapy is currently needed. To this end, we have investigated whether estradiol, ethinylestradiol or ezetimibe could be used as markers for uridine 5'-di-phospho-glucuronosyltransferase isoform 1A1 (UGT1A1) activity restored by AAV gene therapy in Gunn rats, a relevant animal model for CN I. Of these compounds, ezetimibe appeared most suitable because its glucuronidation rate in untreated control Gunn rats is low. Subsequently, ezetimibe glucuronidation was studied in both untreated and AAV-treated Gunn rats and the results suggest that it may serve as a useful serum marker for restored hepatic UGT1A1 activity.

- by Piter Bosma
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- Liver diseases, Biological Sciences, Liver, Physical sciences

The functional heterogeneity of uridine diphosphateglucuronosyltransferase (UDPGT) and its deficiency in human liver were investigated. The monoclonal antibody (MAb) WP1, which inhibits bilirubin and phenol-glucuronidating activity, was used to immunopurify UDPGTs from human liver. Purified UDPGTs were injected into mice to obtain new MAbs. Immunoblotting of microsomes with MAb HEB7 revealed at least three polypeptides in liver (56, 54, and 53 kD) and one in kidney (54 kD). In liver microsomes from four patients (A, B, C, and D) with Crigler-Najjar syndrome type I (CN type I), UDPGT activity towards bilirubin was undetectable (A, B, C, and D) and activity towards phenolic compounds and 5-hydroxytryptamine either reduced (A and B) or normal (C and D). UDPGT activity toward steroids was normal. Immunoblot studies revealed that the monoclonal antibody WP1 recognized two polypeptides (56 and 54 kD) in liver microsomes from patient A and none in patient B. With HEB7 no immunoreactive polypeptides were seen in these two patients. Patient C showed a normal banding pattern and in patient D only the 53-kD band showed decreased intensity. These findings suggest considerable heterogeneity with regard to the expression of UDPGT isoenzymes among CN type I patients. (J. Clin. Invest. 1990. 85:1199-1205.) glucuronidationunconjugated hyperbilirubinemiamonoclonal antibody * immunopurificationhuman liver

- by Ronald Elferink
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- Mice, Monoclonal Antibodies, Immunochemistry, Isoenzymes