- Email: [email protected]
Tu1722 Novel KMT2D Mutation in a Patient With Features of Kabuki Syndrome and Hepatoblastoma
data on consecutive children with biopsy-proven NAFLD including demographics, anthropometrics, and routine laboratory tests. The biopsies were reviewed by an experienced pathologist and histological features were graded according to the NAFLD activity scoring proposed by Kleiner et al. LAL activity (nmol/spot/h) was measured prospectively in dried blood spot using Lalistat 2 per standard protocol. Insulin resistance was evaluated by homeostatic model assessment (HOMA-IR). Spearman rank correlation coefficient (rho) and Analysis of Variance were used to evaluate correlations between LAL activity and histological features. Results: A total of 168 children who had liver biopsy were included for analysis. Mean age was 12.6±8.5 years, 60.1% were males, 52.4 % had NASH and mean LAL activity was 1.3±0.70. There was a weak but significant negative correlation between LAL activity and BMI z-score (rho= -0.28), total cholesterol (rho= -0.22), LDL cholesterol (rho= -0.21), and HOMA-IR (rho= -0.31). Children with clinically significant fibrosis (stage 2-3, n=64) had a significantly lower LAL activity (1.10±0.45) compared to those with mild fibrosis (stage 0-1, n=104, LAL activity 1.4±0.80) with reproduction of similar results after adjusting for age, BMI, triglycerides and cholesterol; p-value <0.05. There was no significant difference in LAL activity between children with NASH (1.2±0.80) compared to those without NASH (1.3±0.57); pvalue = 0.57. Furthermore, there was no correlation between LAL activity and the individual histologic features of NAFLD including steatosis, lobular inflammation, and ballooning. Conclusion: Reduced blood LAL activity correlate with severity of liver fibrosis in children with NAFLD indicating a potential role of reduced LAL activity in the pathogenesis of NAFLD-induced fibrosis. No correlation was found between LAL activity and the presence of NASH.
complications, 37.6% had 3-4 complications, and 36% had 5 or more complications. Of note, the number of extrahepatic comorbidities was significantly increased in children with NASH compared to those in the not NASH group, p < 0.001 (Figure 1) and children with NASH had a 90% increase in the likelihood of having 5 or more complications vs. < 5 complications [OR: 1.9; 95%CI (1.3, 2.7)]. Furthermore, the number of extrahepatic complications correlated with the severity of NAFLD as assessed by the NAFLD activity score and fibrosis stage. Conclusion: Extrahepatic complications are exceedingly common in children presenting with NAFLD with higher frequency in those with NASH and significant fibrosis. We recommend aggressive investigation and management of these complications in conjunction with the management of NAFLD.
Tu1722
AASLD Abstracts
Extrahepatic complications in children with NAFLD Novel KMT2D Mutation in a Patient With Features of Kabuki Syndrome and Hepatoblastoma Kenneth Ng, Andras Heczey
Tu1724
Introduction: Kabuki syndrome is a congenital multi-system disorder. Cardinal features include the "Pentad of Niikawa": dysmorphic facies, skeletal anomalies, dermato-glyphic abnormalities, mental retardation, and postnatal growth deficiency. Visceral involvements include cardiac anomalies, urogenital anomalies and various liver manifestations including biliary atresia, hepatic fibrosis, and neonatal sclerosing cholangitis. Autosomal dominant mutations in either KMT2D or KDM6 account for 50-70% of patients with Kabuki syndrome. This case outlines a patient with the features of Kabuki syndrome that required liver transplantation for unresectable hepatoblastoma found to have a novel variant in the KMT2D gene. Case Description: A 16-month-old former 34-week gestation male initially presented with viral gastroenteritis symptoms and abdominal distension. Medical history included truncus arteriosus s/p repair, pulmonary artery stenosis s/p balloon dilatation, feeding difficulties requiring gastrostomy feeding, growth delay, and speech developmental delay. Physical exam included hepatomegaly, microcephaly, plagiocephaly, central hypotonia, short stature, undescended testes, hearing loss, bifid uvula, and dysmorphic facial features. Abdominal ultrasound showed a large hepatic mass involving both lobes. Alpha feto protein level was 215,800 ng/ml. Abdominal and chest CT confirmed a large, unresectable mass (PRETEXT III) with small calcifications (no metastasis or adenopathy). Liver biopsy was consistent with mixed epithelial and mesenchymal hepatoblastoma. Patient was started on chemotherapy (cisplatin, fluorouracil, vincristine - C5V), but after 2 cycles the tumor remained unresectable. He underwent successful liver transplantation during the 5th cycle with a compatible graft. The explant contained viable hepatoblastoma. He received one additional round of adjuvant chemotherapy post-transplant, and his most recent alpha feto protein was 3.8 ng/ml 3 months after surgery. Whole exome sequencing of the tumor revealed a novel variant in the KMT2D gene (nucleotide: c.3565C>T). Discussion: Our patient has many features consistent with Kabuki syndrome, including elongated palpebral fissures, eversion of the lateral third of the lower eyelids, large cupped ears, intellectual disability, postnatal growth deficiency, microcephaly, congenital heart defect, genitourinary anomalies, cleft palate, and feeding problems. This patient's whole exome sequencing identified a possible new variant of this disease presentation. There is one other case report of hepatoblastoma and Kabuki syndrome in the scientific literature, which only required liver resection. Although liver manifestations are not a cardinal feature, practitioners should evaluate and monitor for hepatic anomalies and hepatoblastoma in patients with Kabuki syndrome.
In Vitro Study of the 2nd-Generation Antisense Oligonucleotide ISIS-TTRRX in Familial Amyloid Polyneuropathy-Specific Induced Pluripotent Stem CellDerived Hepatocyte-Like Cells Christoph Niemietz, Vanessa Sauer, Gursimran Chandhok, Sarah Guttmann, Shuling Guo, Elizabeth J. Ackermann, Andree Zibert, Hartmut Schmidt, Brett Monia Transthyretin-related familial amyloid polyneuropathy (TTR-FAP) is a rare genetic neurodegenerative disease caused by mutations of TTR, a protein that is predominantly secreted by the liver as a tetramer. In the case of mutant TTR, the tetramer undergoes dissociation resulting in misfolding of the monomer protein that ultimately leads to aggregation and fibril deposition in peripheral tissue and organs. To prevent plaque formation, liver transplantation is an accepted treatment method. In order to efficiently prevent the expression of TTR, certain gene silencing strategies for FAP are currently in development. Antisense oligonucleotides (ASO) are artificial nucleotides that bind to and initiate degradation of complementary mRNA sequences. ISIS-TTRRX is one such promising antisense drug developed to treat FAP and is currently being investigated in clinical trials by Isis Pharmaceuticals. By targeting the 3'UTR of wild-type and mutant TTR, ISIS-TTRRX highly reduces TTR secretion. Predicting ASO efficacy and safety in patients is not possible and requires several preclinical studies. In this context, the use of primary cells of FAP patients is impossible due to ethical constraints. For that reason, the use of patient-specific hepatocyte-like cells (HLCs) derived from induced pluripotent stem cells (iPSCs) represents an alternative method to investigate drug efficacy and off-target effects. Briefly, urine of FAP patients was processed for isolation of renal epithelial cells, followed by reprogramming into FAP-iPS cells using nonintegrating episomal vectors. After characterization of pluripotent cell lines, differentiation towards hepatocyte-like cells was accomplished. FAP-iPS cells were treated with crucial growth factors for 14 days. HLCs were characterized by analysis of typical hepatic markers via qRT-PCR, flow cytometry and immunocytochemistry. ISIS-TTRRX was introduced into HLCs by lipofection in order to evaluate gene silencing of TTR. HLCs were identified with similar morphology and gene expression in comparison to HepG2 cells. ISIS-TTRRX treatment of HLCs resulted in downregulated levels of TTR mRNA and protein. qRT-PCR analysis revealed that drug treatment did not induce marked off-target effects on the expression of other hepatocyte marker genes. In summary, our results indicate that iPSCs derived from urine cells of FAP patients can be differentiated into HLCs expressing TTR at comparable levels as HepG2 cells. TTR gene silencing analysis of HLCs may allow the establishment of a patient-specific in vitro platform for evaluating drug effects. Thus, this technology seems appropriately suited for disease modelling and could potentially allow assessment of novel drugs for therapy of liver diseases.
Tu1723 Extrahepatic Complications Are Extremely Common in Children With Nonalcoholic Fatty Liver Disease (NAFLD) and Their Frequency Correlates With NAFLD Histologic Severity Naim Alkhouri, Praveen Kumar Conjeevaram Selvakumar, Mohammad Nasser Kabbany, Rocio Lopez, Antonella Mosca, Claudia Della Corte, Valerio Nobili
Tu1725 Deficiency of Adenosine Deaminase 2 (DADA2); A Rare Cause of Hepatoportal Sclerosis and Non-Cirrhotic Portal Hypertension Hawwa Alao, David Kleiner, Ma Ai Thanda Han, Varun Takyar, Deborah Stone, Patrycja Hoffmann, Amanda Ombrello, Anne Jones, Daniel Kastner, Theo Heller
Background: Recent data in adults suggest that nonalcoholic fatty liver disease (NAFLD) is independently associated with extrahepatic complications such as cardiovascular disease and diabetes. The aim of the current study was to evaluate the prevalence of these complications in a group of children with biopsy-proven NAFLD and assess their association with the histologic al severity of NAFLD. Methods: Consecutive children who presented to our clinic for evaluation of NAFLD and had a liver biopsy were included. The diagnosis of nonalcoholic steatohepatitis (NASH) and the scoring of its individual histological features were done by an experienced pathologist. Patients with NAFLD were divided into two groups: NASH and "not NASH". Data on the following complications were collected: hypertension, masked hypertension (based on ambulatory blood pressure monitoring), ventricular abnormality (based on echocardiogram), hypertriglyceridemia, low HDL, hypercholesterolemia, insulin resistance/diabetes, metabolic syndrome, vitamin D deficiency, and obstructive sleep apnea (based on polysomnogram). Univariable analysis was performed to assess differences between subjects with and without NASH. Proportional odds logistic regression was used to assess the association between number of extrahepatic comorbidities and NAFLD histology. Results: 428 children with biopsy-proven NAFLD were included, 170 with NASH and 258 with no NASH, mean age of 12.2 ± 2.8 years, 60% male, and 89.7% obese. After completing an extensive evaluation, 98.8% of children with NAFLD had at least one extrahepatic complication. Analysis of total number of extrahepatic complications showed that 25.2% had 1-2
AASLD Abstracts
X : 10052$CH02 03-28-16 22:36:37 PDFd : 10052B : e
Background: DADA2 is an inherited recessive genetic mutation that results in the development of intermittent fevers, early-onset lacunar strokes, livedoid rash, hepatosplenomegaly, and systemic vasculopathy in early infancy of affected individuals. We sought to characterize the hepatic manifestations of this disorder. Methods: 17 patients with DADA2, enrolled in a study at the National Human Genomics Research Institute underwent prospective evaluation including laboratory testing and abdominal ultrasound. Patients underwent clinically indicated transjugular liver biopsy with measurement of portal pressure and MRI. Results: Mean age was 12 years old (9 months - 25 years), 76% Caucasian and 52% male. ALT (26 U/L, range 11-80) and AST (29 U/L, range 16-61) were significantly elevated in 5 out of 17 (29%). Among patients with elevated transaminases, average GGT was 68 (range 18-184) and was abnormal in 75%. GGT was higher in those with elevated ALT in comparison to the rest of the cohort (p<0.036). Platelet count was significantly lower in those with elevated ALT in comparison to the rest of the cohort (p<0.006). 4 out of 5 with elevated ALT underwent transjugular liver biopsy with portal pressure measurement. 2 out of 4 had
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complications, 37.6% had 3-4 complications, and 36% had 5 or more complications. Of note, the number of extrahepatic comorbidities was significantly increased in children with NASH compared to those in the not NASH group, p < 0.001 (Figure 1) and children with NASH had a 90% increase in the likelihood of having 5 or more complications vs. < 5 complications [OR: 1.9; 95%CI (1.3, 2.7)]. Furthermore, the number of extrahepatic complications correlated with the severity of NAFLD as assessed by the NAFLD activity score and fibrosis stage. Conclusion: Extrahepatic complications are exceedingly common in children presenting with NAFLD with higher frequency in those with NASH and significant fibrosis. We recommend aggressive investigation and management of these complications in conjunction with the management of NAFLD.
Tu1722
AASLD Abstracts
Extrahepatic complications in children with NAFLD Novel KMT2D Mutation in a Patient With Features of Kabuki Syndrome and Hepatoblastoma Kenneth Ng, Andras Heczey
Tu1724
Introduction: Kabuki syndrome is a congenital multi-system disorder. Cardinal features include the "Pentad of Niikawa": dysmorphic facies, skeletal anomalies, dermato-glyphic abnormalities, mental retardation, and postnatal growth deficiency. Visceral involvements include cardiac anomalies, urogenital anomalies and various liver manifestations including biliary atresia, hepatic fibrosis, and neonatal sclerosing cholangitis. Autosomal dominant mutations in either KMT2D or KDM6 account for 50-70% of patients with Kabuki syndrome. This case outlines a patient with the features of Kabuki syndrome that required liver transplantation for unresectable hepatoblastoma found to have a novel variant in the KMT2D gene. Case Description: A 16-month-old former 34-week gestation male initially presented with viral gastroenteritis symptoms and abdominal distension. Medical history included truncus arteriosus s/p repair, pulmonary artery stenosis s/p balloon dilatation, feeding difficulties requiring gastrostomy feeding, growth delay, and speech developmental delay. Physical exam included hepatomegaly, microcephaly, plagiocephaly, central hypotonia, short stature, undescended testes, hearing loss, bifid uvula, and dysmorphic facial features. Abdominal ultrasound showed a large hepatic mass involving both lobes. Alpha feto protein level was 215,800 ng/ml. Abdominal and chest CT confirmed a large, unresectable mass (PRETEXT III) with small calcifications (no metastasis or adenopathy). Liver biopsy was consistent with mixed epithelial and mesenchymal hepatoblastoma. Patient was started on chemotherapy (cisplatin, fluorouracil, vincristine - C5V), but after 2 cycles the tumor remained unresectable. He underwent successful liver transplantation during the 5th cycle with a compatible graft. The explant contained viable hepatoblastoma. He received one additional round of adjuvant chemotherapy post-transplant, and his most recent alpha feto protein was 3.8 ng/ml 3 months after surgery. Whole exome sequencing of the tumor revealed a novel variant in the KMT2D gene (nucleotide: c.3565C>T). Discussion: Our patient has many features consistent with Kabuki syndrome, including elongated palpebral fissures, eversion of the lateral third of the lower eyelids, large cupped ears, intellectual disability, postnatal growth deficiency, microcephaly, congenital heart defect, genitourinary anomalies, cleft palate, and feeding problems. This patient's whole exome sequencing identified a possible new variant of this disease presentation. There is one other case report of hepatoblastoma and Kabuki syndrome in the scientific literature, which only required liver resection. Although liver manifestations are not a cardinal feature, practitioners should evaluate and monitor for hepatic anomalies and hepatoblastoma in patients with Kabuki syndrome.
In Vitro Study of the 2nd-Generation Antisense Oligonucleotide ISIS-TTRRX in Familial Amyloid Polyneuropathy-Specific Induced Pluripotent Stem CellDerived Hepatocyte-Like Cells Christoph Niemietz, Vanessa Sauer, Gursimran Chandhok, Sarah Guttmann, Shuling Guo, Elizabeth J. Ackermann, Andree Zibert, Hartmut Schmidt, Brett Monia Transthyretin-related familial amyloid polyneuropathy (TTR-FAP) is a rare genetic neurodegenerative disease caused by mutations of TTR, a protein that is predominantly secreted by the liver as a tetramer. In the case of mutant TTR, the tetramer undergoes dissociation resulting in misfolding of the monomer protein that ultimately leads to aggregation and fibril deposition in peripheral tissue and organs. To prevent plaque formation, liver transplantation is an accepted treatment method. In order to efficiently prevent the expression of TTR, certain gene silencing strategies for FAP are currently in development. Antisense oligonucleotides (ASO) are artificial nucleotides that bind to and initiate degradation of complementary mRNA sequences. ISIS-TTRRX is one such promising antisense drug developed to treat FAP and is currently being investigated in clinical trials by Isis Pharmaceuticals. By targeting the 3'UTR of wild-type and mutant TTR, ISIS-TTRRX highly reduces TTR secretion. Predicting ASO efficacy and safety in patients is not possible and requires several preclinical studies. In this context, the use of primary cells of FAP patients is impossible due to ethical constraints. For that reason, the use of patient-specific hepatocyte-like cells (HLCs) derived from induced pluripotent stem cells (iPSCs) represents an alternative method to investigate drug efficacy and off-target effects. Briefly, urine of FAP patients was processed for isolation of renal epithelial cells, followed by reprogramming into FAP-iPS cells using nonintegrating episomal vectors. After characterization of pluripotent cell lines, differentiation towards hepatocyte-like cells was accomplished. FAP-iPS cells were treated with crucial growth factors for 14 days. HLCs were characterized by analysis of typical hepatic markers via qRT-PCR, flow cytometry and immunocytochemistry. ISIS-TTRRX was introduced into HLCs by lipofection in order to evaluate gene silencing of TTR. HLCs were identified with similar morphology and gene expression in comparison to HepG2 cells. ISIS-TTRRX treatment of HLCs resulted in downregulated levels of TTR mRNA and protein. qRT-PCR analysis revealed that drug treatment did not induce marked off-target effects on the expression of other hepatocyte marker genes. In summary, our results indicate that iPSCs derived from urine cells of FAP patients can be differentiated into HLCs expressing TTR at comparable levels as HepG2 cells. TTR gene silencing analysis of HLCs may allow the establishment of a patient-specific in vitro platform for evaluating drug effects. Thus, this technology seems appropriately suited for disease modelling and could potentially allow assessment of novel drugs for therapy of liver diseases.
Tu1723 Extrahepatic Complications Are Extremely Common in Children With Nonalcoholic Fatty Liver Disease (NAFLD) and Their Frequency Correlates With NAFLD Histologic Severity Naim Alkhouri, Praveen Kumar Conjeevaram Selvakumar, Mohammad Nasser Kabbany, Rocio Lopez, Antonella Mosca, Claudia Della Corte, Valerio Nobili
Tu1725 Deficiency of Adenosine Deaminase 2 (DADA2); A Rare Cause of Hepatoportal Sclerosis and Non-Cirrhotic Portal Hypertension Hawwa Alao, David Kleiner, Ma Ai Thanda Han, Varun Takyar, Deborah Stone, Patrycja Hoffmann, Amanda Ombrello, Anne Jones, Daniel Kastner, Theo Heller
Background: Recent data in adults suggest that nonalcoholic fatty liver disease (NAFLD) is independently associated with extrahepatic complications such as cardiovascular disease and diabetes. The aim of the current study was to evaluate the prevalence of these complications in a group of children with biopsy-proven NAFLD and assess their association with the histologic al severity of NAFLD. Methods: Consecutive children who presented to our clinic for evaluation of NAFLD and had a liver biopsy were included. The diagnosis of nonalcoholic steatohepatitis (NASH) and the scoring of its individual histological features were done by an experienced pathologist. Patients with NAFLD were divided into two groups: NASH and "not NASH". Data on the following complications were collected: hypertension, masked hypertension (based on ambulatory blood pressure monitoring), ventricular abnormality (based on echocardiogram), hypertriglyceridemia, low HDL, hypercholesterolemia, insulin resistance/diabetes, metabolic syndrome, vitamin D deficiency, and obstructive sleep apnea (based on polysomnogram). Univariable analysis was performed to assess differences between subjects with and without NASH. Proportional odds logistic regression was used to assess the association between number of extrahepatic comorbidities and NAFLD histology. Results: 428 children with biopsy-proven NAFLD were included, 170 with NASH and 258 with no NASH, mean age of 12.2 ± 2.8 years, 60% male, and 89.7% obese. After completing an extensive evaluation, 98.8% of children with NAFLD had at least one extrahepatic complication. Analysis of total number of extrahepatic complications showed that 25.2% had 1-2
AASLD Abstracts
X : 10052$CH02 03-28-16 22:36:37 PDFd : 10052B : e
Background: DADA2 is an inherited recessive genetic mutation that results in the development of intermittent fevers, early-onset lacunar strokes, livedoid rash, hepatosplenomegaly, and systemic vasculopathy in early infancy of affected individuals. We sought to characterize the hepatic manifestations of this disorder. Methods: 17 patients with DADA2, enrolled in a study at the National Human Genomics Research Institute underwent prospective evaluation including laboratory testing and abdominal ultrasound. Patients underwent clinically indicated transjugular liver biopsy with measurement of portal pressure and MRI. Results: Mean age was 12 years old (9 months - 25 years), 76% Caucasian and 52% male. ALT (26 U/L, range 11-80) and AST (29 U/L, range 16-61) were significantly elevated in 5 out of 17 (29%). Among patients with elevated transaminases, average GGT was 68 (range 18-184) and was abnormal in 75%. GGT was higher in those with elevated ALT in comparison to the rest of the cohort (p<0.036). Platelet count was significantly lower in those with elevated ALT in comparison to the rest of the cohort (p<0.006). 4 out of 5 with elevated ALT underwent transjugular liver biopsy with portal pressure measurement. 2 out of 4 had
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Page 1172