Genetics of Familial Intrahepatic Cholestasis Syndromes S W C Van Mil, R H J Houwen, L W J Klomp
Total Page:16
File Type:pdf, Size:1020Kb
449 REVIEW J Med Genet: first published as 10.1136/jmg.2004.026187 on 3 June 2005. Downloaded from Genetics of familial intrahepatic cholestasis syndromes S W C van Mil, R H J Houwen, L W J Klomp ............................................................................................................................... J Med Genet 2005;42:449–463. doi: 10.1136/jmg.2004.026187 Bile acids and bile salts have essential functions in the liver During the last decade, many loci underlying intrahepatic cholestasis have been mapped, the and in the small intestine. Their synthesis in the liver genes have been identified, and protein functions provides a metabolic pathway for the catabolism of have been studied. Taken together with the cholesterol and their detergent properties promote the recent exciting discovery of nuclear hormone receptors that act as bile acid sensors by solubilisation of essential nutrients and vitamins in the small transcriptional regulation of key enzymes and intestine. Inherited conditions that prevent the synthesis of transporters in bile acid metabolism, these bile acids or their excretion cause cholestasis, or impaired studies have allowed a detailed understanding of the molecular mechanisms and regulation of bile flow. These disorders generally lead to severe human bile formation. This review summarises recent liver disease, underscoring the essential role of bile acids in insights into the genetics of familial intrahepatic metabolism. Recent advances in the elucidation of gene cholestasis syndromes and the functions and defects underlying familial cholestasis syndromes has regulation of the affected proteins. We have divided most familial cholestasis syndromes in greatly increased knowledge about the process of bile flow. classes comprising bile acid synthesis defects and The expression of key proteins involved in bile flow is tightly bile salt transport defects because the genetic regulated by transcription factors of the nuclear hormone disorders in these different classes have common aspects in disease outcome and possible treat- receptor family, which function as sensors of bile acids and ment, which will be discussed below. We have cholesterol. Here we review the genetics of familial classified a defect in bile acid conjugation as a cholestasis disorders, the functions of the affected genes in synthesis defect and we tentatively consider familial intrahepatic cholestasis type 1 (FIC1) bile flow, and their regulation by bile acids and cholesterol. disease as a bile salt transport defect, although ........................................................................... the exact mode by which FIC1 disease causes intrahepatic cholestasis is unknown. ach day, approximately 500 mg of bile acids are synthesised from cholesterol in the adult PHYSIOLOGY AND CELL BIOLOGY OF Ehuman liver. Newly synthesised bile acids BILE FORMATION http://jmg.bmj.com/ are conjugated with either glycine or taurine and Biliary excretion of different compounds is an subsequently secreted into bile and stored in the important function of the liver. Synthesis and gallbladder. Biliary secretion of bile salts against a concentration gradient requires the hydrolysis of adenosine triphosphate (ATP) and this process Abbreviations: ABC, ATP-binding cassette; AKR1D1, D4-3-oxosteroid-5b reductase; AMACR, 2-methylacyl- provides the driving force for bile flow. Because CoA racemase; ASBT, apical sodium-dependent bile salt of their detergent properties, bile acids are transporter; ATP, adenosine triphosphate; BAAT, bile acid on October 2, 2021 by guest. Protected copyright. inherently cytotoxic, and hence it is important CoA:amino acid N-acyltransferase; BRIC, benign that intracellular levels of bile acids are tightly recurrent intrahepatic cholestasis; BSEP, bile salt export regulated. This is largely accomplished by tran- pump; C27 3b-HSD, 3b-D5-C27-hydroxysteroid oxidoreductase; CA, cholic acid; CDCA, scriptional regulation of genes encoding proteins chenodeoxycholic acid; CEA, carcinoembryonic antigen; involved in bile acid synthesis and transport. CTX, cerebrotendinous xanthomatosis; DCA, deoxycholic Cholestasis, or impaired bile flow, is one of the acid; DHCA, dihydroxycholestanoic acid; FHCA, familial most common and devastating manifestations of hypercholanaemia; FIC1, familial intrahepatic cholestasis liver disease. Cholestasis is clinically charac- type 1; FXR, farnesoid X receptor; GFC, Greenland terised by elevated plasma concentrations of familial cholestasis; GGT, gamma-glutamyl See end of article for transpeptidase; GPI, glycosyl phosphatidyl inositol; authors’ affiliations biliary constituents, resulting in jaundice, malab- HSD3B7, 3b-D5-C27-hydroxysteroid oxidoreductase; ....................... sorption of fats and fat-soluble vitamins and, in IBABP, ileal bile acid binding protein; ICP, intrahepatic Correspondence to: many cases, progressive liver damage. Both cholestasis of pregnancy; LCA, lithocholic acid; LCS, Leo W J Klomp, University acquired and hereditary forms of cholestasis lymphoedema-cholestasis syndrome; LXRa, liver X Medical Center Utrecht, have been described. Familial intrahepatic cho- receptor a; mEH, microsomal epoxide hydrolase; NAICC, North American Indian childhood cirrhosis; NTCP, Room KC02.069.1, lestasis syndromes can be caused by a deficiency Lundlaan 6, 3584 EA sodium-dependent taurocholate protein; OATP, organic Utrecht, The Netherlands; either in bile acid synthesis or in the transport of anion transporter; PBAM, primary bile acid [email protected] bile salts into bile. Elucidation of the gene defects malabsorption; PC, phosphatidyl choline; PFIC, underlying these hereditary cholestasis syn- progressive familial intrahepatic cholestasis; PXR, Revised version received dromes is of critical importance for our under- pregnane X receptor; SHP, short heterodimeric partner; 5 August 2004 tASBT, truncated form of ASBT; THCA, Accepted for publication standing of hereditary cholestasis and, trihydroxycholestanoic acid; TJP2, tight junction protein 2; 24 August 2004 consequently, for our knowledge of the process UDCA, ursodeoxycholic acid; VDR, vitamin D nuclear ....................... of bile acid synthesis and transport. receptor www.jmedgenet.com 450 van Mil, Houwen, Klomp transport of bile acids are essential for efficient bile flow. Bile bile acids enter the colon, the hydroxyl group at C-7 is acids are synthesised in the liver and stored in the removed by anaerobic bacteria, and 7-deoxy bile acids are J Med Genet: first published as 10.1136/jmg.2004.026187 on 3 June 2005. Downloaded from gallbladder. Upon digestion of a meal, bile salts are delivered formed. By this process, CA is converted to deoxycholic acid to the lumen of the small intestine where they act as (DCA) and CDCA is converted to lithocholic acid (LCA). DCA emulsifiers of dietary lipids, cholesterol, and fat-soluble and LCA are called secondary bile acids because they are vitamins. Bile salts are converted by intestinal bacteria, formed from primary bile acids in the intestine. Both are transported from the intestine to the liver via the portal reabsorbed in the colon by an unknown mechanism and circulation, and subsequently resecreted into bile. returned to the liver. In the liver, DCA is conjugated with Approximately 95% of bile salts are recovered in the gut glycine or taurine and circulates with the primary bile acids. during each cycle of this enterohepatic circulation, and the In contrast, LCA is conjugated with glycine or taurine and 5% that are lost via the faeces are replaced by de novo additionally sulfated at the C-3 position. These sulfated bile synthesis in the liver (fig 1A). salts are secreted into bile but are not efficiently absorbed In fig 1B, some important transport proteins involved in from the intestine and are therefore eliminated from the body the enterohepatic circulation of bile salts are depicted via the faeces.45 schematically. As can be seen from this figure, the Bile acids are cytotoxic when their concentrations increase enterohepatic circulation of bile salts requires regulated to abnormally high levels intracellularly or extracellularly and vectorial transport of bile salts in polarised epithelial cells, this cytotoxicity is strongly dependent on their physicochem- such as the hepatocyte and the enterocyte. The bile salt ical properties. CA is the most hydrophilic bile acid with three export pump (BSEP) mediates secretion of bile salts from the hydroxy groups and is therefore less cytotoxic, whereas DCA apical domains of hepatocytes into bile. In the intestine, the and CDCA are more harmful because they only have two apical sodium-dependent bile salt transporter (ASBT) is hydroxyl groups. LCA is the most cytotoxic naturally responsible for reabsorption of bile acids at the brush border, occurring bile acid with only one hydroxyl group. UDCA, a while the ileal bile acid binding protein (IBABP) is thought to naturally occurring bile acid in black bears but detected in transport bile acids through the cytoplasm of the enterocytes humans only in trace amounts, is devoid of cytotoxic to the basolateral membrane. A truncated form of ASBT properties; this bile acid is relatively hydrophilic, although (tASBT) transports bile acids from the enterocytes into the it is a di-hydroxy bile acid, but the hydroxyl group at C-7 is in blood. At the basolateral membrane of the hepatocytes, the the b rather than the a configuration as in CDCA.6 UDCA is sodium-dependent taurocholate protein (NTCP) and to a used as a