Clinical and genetic characterisation of infantile liver failure syndrome type 1, due to recessive mutations in LARS
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Recessive LARS mutations were recently reported to cause a novel syndrome, infantile liver failure syndrome type 1 (ILFS1), in six Irish Travellers. We have since identified four additional patients, including one of Ashkenazi origin, representing the largest ILFS1 cohort to date. Our study aims to define the ILFS1 clinical phenotype to help guide diagnosis and patient management.
We clinically evaluated and reviewed the medical records of ten ILFS1 patients. Clinical features, histopathology and natural histories were compared and patient management strategies reviewed.
Early failure to thrive, recurrent liver dysfunction, anemia, hypoalbuminemia and seizures were present in all patients. Most patients (90 %) had developmental delay. Encephalopathic episodes triggered by febrile illness have occurred in 80 % and were fatal in two children. Two patients are currently >28 years old and clinically well. Leucine supplementation had no appreciable impact on patient well-being. However, we suggest that the traditional management of reducing/stopping protein intake in patients with metabolic hepatopathies may not be appropriate for ILFS1. We currently recommend ensuring sufficient natural protein intake when unwell.
We report the first non-Irish ILFS1 patient, suggesting ILFS1 may be more extensive than anticipated. Low birth weight, early failure to thrive, anemia and hypoalbuminemia are amongst the first presenting features, with liver dysfunction before age 1. Episodic hepatic dysfunction is typically triggered by febrile illness, and becomes less severe with increasing age. While difficult to anticipate, two patients are currently >28 years old, suggesting that survival beyond childhood may be associated with a favourable long-term prognosis.
KeywordsAcute Liver Failure Aminoacyl tRNA Synthetase Microcytic Anemia Leucine Supplement Leigh Disease
We sincerely thank the patients and their families who have contributed to this study and helped our understanding of childhood liver disease. We would also like to thank Prof. David Wilson (Professor of Paediatric Gastroenterology and Nutrition at the University of Edinburgh) for his insightful discussions on albuminemia and amino acid homeostasis and Dr Seamus Hussey and Dr Annemarie Broderick for stimulating discussions on mechanisms of liver disease.
The genetic studies were supported by The Children's Fund for Health, Temple Street Children's University Hospital, Dublin, Ireland (PAC 09131). Jillian Casey is supported by a Medical Research Charities Group (MRCG) grant from the Health Research Board (HRB) and the Children’s Fund for Health, Temple Street Children’s University Hospital (MRCG/2013/02).
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Conflict of interest
- All Ireland Traveller Health Study Team (2011) School of Public Health, Physiotherapy and Population Science, University College Dublin, Ireland. All Ireland Traveller Healthy Study. Our GeelsGoogle Scholar