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Autoimmune BSEP Disease: Disease Recurrence After Liver Transplantation for Progressive Familial Intrahepatic Cholestasis

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Abstract

Severe cholestasis may result in end-stage liver disease with the need of liver transplantation (LTX). In children, about 10 % of LTX are necessary because of cholestatic liver diseases. Apart from bile duct atresia, three types of progressive familial intrahepatic cholestasis (PFIC) are common causes of severe cholestasis in children. The three subtypes of PFIC are defined by the involved genes: PFIC-1, PFIC-2, and PFIC-3 are due to mutations of P-type ATPase ATP8B1 (familial intrahepatic cholestasis 1, FIC1), the ATP binding cassette transporter ABCB11 (bile salt export pump, BSEP), or ABCB4 (multidrug resistance protein 3, MDR3), respectively. All transporters are localized in the canalicular membrane of hepatocytes and together mediate bile salt and phospholipid transport. In some patients with PFIC-2 disease, recurrence has been observed after LTX, which mimics a PFIC phenotype. It could be shown by several groups that inhibitory anti-BSEP antibodies emerge, which most likely cause disease recurrence. The prevalence of severe BSEP mutations (e.g., splice site and premature stop codon mutations) is very high in this group of patients. These mutations often result in the complete absence of BSEP, which likely accounts for an insufficient auto-tolerance against BSEP. Although many aspects of this “new” disease are not fully elucidated, the possibility of anti-BSEP antibody formation has implications for the pre- and posttransplant management of PFIC-2 patients. This review will summarize the current knowledge including diagnosis, pathomechanisms, and management of “autoimmune BSEP disease.”

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Abbreviations

BRIC:

Benign recurrent intrahepatic cholestasis

PFIC:

Progressive familial intrahepatic cholestasis

BSEP:

Bile salt export pump

LTX:

Liver transplantation

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Acknowledgments

The authors would like to thank Annette Tries, Nicole Eichhorst, and Paulina Philippski for expert technical support throughout the ongoing study of this disease.

This review is dedicated to Prof. Dr. Med. Martin Burdelski.

Financial Support

This study was supported by the Clinical Research Group KFO217 “Hepatobiliary transport and liver diseases” and the Collaborative Research Centre 974 “Communication and Systemic Impact in Liver Damage and Regeneration.”

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Authors and Affiliations

  1. Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany

    Ralf Kubitz, Carola Dröge, Stefanie Kluge, Claudia Stross, Nathalie Walter, Verena Keitel, Dieter Häussinger & Jan Stindt

  2. Department of Gastroenterology, Hepatology, Diabetology and Oncology, Krankenhaus Bethanien, Bethanienstr. 21, 47441, Moers, Germany

    Ralf Kubitz

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  1. Ralf Kubitz
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Kubitz, R., Dröge, C., Kluge, S. et al. Autoimmune BSEP Disease: Disease Recurrence After Liver Transplantation for Progressive Familial Intrahepatic Cholestasis. Clinic Rev Allerg Immunol 48, 273–284 (2015). https://doi.org/10.1007/s12016-014-8457-4

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