Pediatric Intestinal Failure–Associated Liver Disease: Challenges in Identifying Clinically Relevant Biomarkers |
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| Authors: | Kathleen M. Gura PharmD Andrew E. Mulberg MD FAAP CPI Paul D. Mitchell MS John Yap PhD Clara Y. Kim PhD Minjun Chen PhD Alexis Potemkin BSN Mark Puder MD PhD |
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| Affiliation: | 1. Department of Pharmacy, Boston Children’s Hospital, Boston, Massachusetts, USA;2. Division of Gastroenterology and Inborn Error Products, Office of Drug Evaluation III, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA;3. Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts, USA;4. Office of Biostatistics/Division of Biometrics 7, Office of Drug Evaluation III, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA;5. National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arizona, USA;6. Department of Nursing, Boston Children’s Hospital, Boston, Massachusetts, USA;7. Vascular Biology Program and Department of Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA |
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| Abstract: | Background: Intestinal failure–associated liver disease (IFALD) is complex and diagnosed by concurrent use of parenteral nutrition, clinical presentation, and alterations in hepatic biomarkers exclusive of other causes of liver disease. In comparison with individual measures, composite biomarkers may provide a more effective means for assessing disease progression and response to treatment than single parameters. Since IFALD is considered by some to be a type of drug‐induced liver injury (DILI), those diagnostic criteria could potentially be used in this population. Using a preexisting database of children treated for IFALD, our aim was to determine if a similar composite biomarker could be applied to this population. Study Design: Adult DILI criteria were applied at baseline, when treatment for IFALD (ie, direct bilirubin ≥2.0 mg/dL) was initiated. Results: A total of 214 patients with IFALD treated at Boston Children’s Hospital were identified; 168 patients were eligible for analysis. Most patients analyzed were male (61%) and preterm (87%). Alkaline phosphatase (ALP) ≥2× upper limit of normal (ULN) captured the least amount of DILI (11%), while γ‐glutamyltransferase (GGT) ≥1× ULN accounted for the most (62%). Using adult DILI criteria, 60 (39%) patients with IFALD were found to have DILI. Substituting GGT ≥1× ULN for ALP ≥2× ULN improved the sensitivity, with 105 (69%) of patients meeting at least 1 criterion for DILI. Conclusion: Numerous challenges made it difficult to apply the DILI criteria to children with IFALD. Direct bilirubin, fractionated ALP, and perhaps GGT may be more suitable. Given its complex etiology and the age‐based differences due to hepatic immaturity and growth, a more suitable composite marker needs to be developed to assess IFALD in this population. |
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| Keywords: | biomarker cholestasis composite biomarker parenteral nutrition nutrition phytosterols |
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