北方地区单中心Citrin蛋白缺陷所致婴儿肝内胆汁淤积症23例临床特征及基因分析

刘文雯; 马昕; 王美娟; 宁慧娟; 钟雪梅

doi:10.3969/j.issn.1001-5256.2021.05.035

北方地区单中心Citrin蛋白缺陷所致婴儿肝内胆汁淤积症23例临床特征及基因分析

DOI: 10.3969/j.issn.1001-5256.2021.05.035

首都儿科研究所附属儿童医院消化内科，北京 100020

基金项目:

北京市医院管理局消化内科学科协同发展中心重点项目 (XXZ0505)

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。

作者贡献声明：刘文雯负责课题设计，资料分析，撰写论文；马昕、王美娟、宁慧娟参与收集数据，修改论文；钟雪梅负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

作者简介:
刘文雯(1991—)，女，主要从事小儿肝胆方面的研究

通信作者:
钟雪梅，zhognxuemei@shouer.com.cn

中图分类号: R657.4
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出版历程
- 收稿日期: 2020-10-16
- 录用日期: 2020-11-02
- 出版日期: 2021-05-20

Clinical and genetic features of neonatal intrahepatic cholestasis caused by citrin deficiency in northern China: A single-center analysis of 23 cases

Department of Gastroenterology, Children's Hospital, Capital Institute of Pediatrics, Beijing 100020, China

摘要

摘要: 目的探讨北方地区Citrin蛋白缺陷所致的婴儿胆汁淤积症的临床特征及基因突变特点。方法选取2015年1月—2018年12月首都儿科研究所附属儿童医院消化内科经血串联质谱和/或基因检测诊断的23例北方地区Citrin蛋白缺陷所致的肝内胆汁淤积症(NICCD)患儿为NICCD组，同时期经过一系列系统检查后仍未明确病因的36例特发性肝内胆汁淤积症(INC)患儿为INC组，回顾性分析NICCD组患儿的临床表现、实验室检查结果、病理、血尿代谢筛查和基因结果，随访患儿转归情况，并对两组生化指标进行比较。符合正态分布的计量资料两组间比较采用独立样本t检验；非正态分布的计量资料两组间比较采用Mann-Whitney U检验。计数资料两组间比较采用χ²检验。结果 23例NICCD患儿中，伴有低血糖患儿10例，伴有低白蛋白血症患儿13例，伴有高血氨患儿17例，伴有高乳酸患儿15例；15例LDL升高，6例胆固醇升高，7例甘油三酯升高；17例PT延长，16例患儿APTT延长。与INC组对比，NICCD组GGT、TBA、活化部分凝血活酶时间(APTT)明显高于INC组，Alb较INC组为低，差异均具有统计学意义(Z=-2.487、Z=-3.528、t=3.532、t=-2.24，P值均 < 0.05)。NICCD组患儿血串联质谱中最常见异常是精氨酸、瓜氨酸、甲硫氨酸及游离肉碱、长链酰基肉碱水平的升高，尿气相色谱提示最常见的4-羟基苯乳酸、半乳糖、半乳糖醇、半乳糖酸的升高。23例均行基因检测，发现致病突变16种，其中新发现突变7种，为IVS14-9A>G、c1640 G>A、c.762T>A、c.736delG、c.1098 T del、c.851G>A、c.550G>A。除2例患儿失访外，21例患儿经过治疗2~6个月后转氨酶及胆红素水平逐渐恢复正常，随访至1岁，患儿均无生长发育落后，其中2例患儿出现饮食偏好(喜食鱼类、肉类，不喜主食)。结论血GGT、TBA、Alb、APTT指标的异常可为NICCD与INC鉴别诊断提供思路。北方地区NICCD基因突变具有异质性，大部分患儿预后良好。
- 胆汁淤积, 肝内 /
- 高通量核苷酸序列分析 /
- 预后
Abstract: Objective To investigate the clinical features and gene mutation characteristics of neonatal intrahepatic cholestasis caused citrin deficiency (NICCD) in northern China. Methods A total of 23 pediatric patients in northern China who were diagnosed with NICCD by blood tandem mass spectrometry and/or gene detection in Department of Gastroenterology, Children's Hospital Affiliated to Capital Institute of Pediatrics, from January 2015 to December 2018 were enrolled as NICCD group, and 36 pediatric patients with idiopathic neonatal cholestasis (INC) who had unclarified etiology after a series of examinations during the same period of time were enrolled as INC group. A retrospective analysis was performed for the clinical manifestation, laboratory examination, pathology, blood/urine metabolic screening, and gene sequencing results of the pediatric patients in the NICCD group, and follow-up was performed to observe their outcome; biochemical parameters were compared between the two groups. The independent samples t-test was used for comparison of normally distributed continuous data, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data; the chi-square test was used for comparison of categorical data between groups. Results Among the 23 patients in the NICCD group, 10 had hypoglycemia, 13 had hypoalbuminemia, 17 had hyperammonemia, and 15 had hyperlactacidemia; 15 had an increase in low-density lipoprotein, 6 had an increase in cholesterol, and 7 had an increase in triglyceride; 17 had prolonged prothrombin time, and 16 had prolonged activated partial thromboplastin time (APTT). Compared with the INC group, the NICCD group had significantly higher gamma-glutamyl transpeptidase (GGT), total bile acid (TBA), and APTT and a significantly lower albumin (Alb) level (Z=-2.487, Z=-3.528, t=3.532, t=-2.24, all P < 0.05). For the patients with NICCD, blood tandem mass spectrometry showed that the most common abnormalities were the increased levels of arginine, citrulline, methionine, free carnitine, and long-chain acylcarnitine, while urinary gas chromatography showed the increased levels of 4-hydroxyphenyllactic acid, galactose, galactitol, and galactonic acid. Gene detection was performed for all 23 patients and identified 16 pathogenic mutations, among which 7 were newly discovered, namely ivs14-9a>G, c1640 G>A, c.762T>A, c.736delG, c.1098 T del, c.851G>A, and c.550G>A. Except for the 2 patients who were lost to follow-up, the levels of aminotransferases and bilirubin gradually returned to normal in 21 patients after 2-6 months of treatment; none of them showed delayed growth and development after being followed up to the age of 1 year, and 2 of them developed dietary preference (they liked fish and meat and did not like staple food). Conclusion Abnormalities of blood GGT, TBA, Alb, and APTT may provide ideas for the differential diagnosis of NICCD and INC. NICCD gene mutations in northern China are heterogeneous and most patients tend to have a good prognosis.
- Cholestasis, Intrahepatic /
- High-Throughput Nucleotide Sequencing /
- Prognosis

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图 1 PCR扩增显示IVS16ins3kb缺失突变

注：1，阴性对照；2，阳性对照；3，患儿；4，患儿父亲；5，患儿母亲。

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图 2 c.852_855del突变先证者及其父母验证

注：a，先证者杂合突变；b，父亲无变异；c，母亲杂合突变。

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图 3 c.615+5G>A突变先证者及其父母验证

注：a，先证者杂合突变；b，父亲纯合突变；c，母亲无变异。

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表 1 NICCD组与INC组临床表现比较

临床表现	NICCD组(n=23)	INC组(n=36)	χ²值	P值
深色尿[例(%)]	18(78)	27(75)	0.177	0.674
陶土便[例(%)]	3(13)	4(11)	0.031	0.861
浅色便[例(%)]	9(39)	16(44)	2.452	0.117
肝肿大[例(%)]	13(56)	21(58)	0.007	0.934
脾肿大[例(%)]	5(21)	4(11)	0.333	0.564
早产(< 35周)[例(%)]	0	4(11)	1.176	0.278
LBW[例(%)]	4(17)	8(22)	0.014	0.906
营养不良[例(%)]	1(4)	17(47)	12.168	0.001
注：LBW，低出生体质量；营养不良指患儿就诊时体质量低于同月龄同性别婴儿第3百分位。

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表 2 NICCD组与INC组实验室检查结果对比

实验室指标	NICCD组(n=23)	INC组(n=36)	统计值	P值
ALT(U/L)	72.9(44.1~304.9)	120.5(93.0~320.0)	Z=-1.679	>0.05
AST(U/L)	179.6(121.8~438.9)	204.0(149.8~304.9)	Z=-0.155	>0.05
TBil(μmol/L)	147.1(122.9~186.7)	149.3(110.1~205.5)	Z=-0.28	>0.05
DBil(μmol/L)	73.7(63.0~98.5)	95.5(78.7~116.7)	Z=-1.873	>0.05
GGT(U/L)	211.0(103.5~248.4)	87.0(66.3~167.2)	Z=-2.487	0.013
TBA(μmol/l)	210.22(140.0~284.6)	123.6(98.7~163.5)	Z=-3.528	0.001
Alb(g/L)	35.11±5.59	38.30±5.09	t=-2.24	0.029
血糖(mmol/L)	3.36±1.50	3.65±1.24	t=-1.307	>0.05
乳酸(mmol/L)	2.72±0.81	2.10±0.86	t=1.994	>0.05
血氨(μmol/l)	53.07±23.69	43.46±18.78	t=1.401	>0.05
TC(mmol/L)	4.72±1.43	4.02±1.43	t=1.811	>0.05
LDL(mmol/L)	2.86±1.22	2.61±1.11	t=0.817	>0.05
TG(mmol/L)	1.95±0.72	1.64±0.61	t=1.78	>0.05
PT(s)	14.42±4.16	12.31±4.74	t=1.704	>0.05
APTT(s)	48.92±13.63	37.37±8.04	t=3.532	0.001

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表 3 23例NICCD患儿一般情况及SLC25A13基因突变检测结果

编号	性别	籍贯	体质量(g)	SLC25A13基因突变	突变来源
1	男	河南	3300	c851-854GTATdel/c.1098Tdel	母亲/自发
2	男	山西	3100	c851-854GTATdel/IVS14-9A>G	×
3	女	内蒙古	2500	c.852_855TATCdel/c.762T>A	母亲/父亲
4	男	河北	3150	c.852_855delTATG/c.1633_1664insCCCGGGCAGCCACCGTAATCTC	×
5	男	北京	2650	c.852_855TATCdel /c.550G>A	×
6	女	北京	3000	c.852_855del/IVS16ins3kb	母亲/父亲
7	男	山西	2300	c.852_855del/c.615+5G>A	母亲/父亲
8	女	河南	3250	IVS16ins3kb/c.736delG	母亲/父亲
9	男	河北	3000	IVS16ins3kb/IVS16ins3kb	父亲/母亲
10	女	山西	3800	c.1194A>G/c.1194A>G	×
11	男	山东	2900	c.1194A>G/c.1194A>G	×
12	男	北京	2730	c.1194A>G/c.1194A>G	×
13	男	河北	3600	c.1194A>G/c.1194A>G	×
14	男	山西	3200	c.1194A>G/c.1194A>G	×
15	女	河南	2900	c1640 G>A/c1640G>A	母亲
16	女	北京	3150	c.2T>C / c.851G>A	×
17	男	北京	2350	c851-854GTATdel/—	父亲
18	男	河南	2900	c.1177+1G>A/—	×
19	男	山东	2800	c.1660_1661insCCCGGGCAGCCACCTGTAATCTC/—	×
20	男	河北	3000	c.615+5G>A/—	×
21	女	山东	3000	c.1177+1G>A/—	×
22	男	河北	3000	c.2T>C/—	父亲
23	男	河北	2000	c.2T>C/—	母亲
注：×，未检测。

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参考文献(15)

[1]	KOBAYASHI K, SINASAC DS, ⅡJIMA M, et al. The gene mutated in adult-onset type Ⅱ citrullinaemia encodes a putative mitochondrial carrier protein[J]. Nat Genet, 1999, 22(2): 159-163. DOI: 10.1038/9667.
[2]	SONG YZ, DENG M, CHEN FP, et al. Genotypic and phenotypic features of citrin deficiency: Five year experience in a Chinese pediatric center[J]. Int J Mol Med, 2011, 28(1): 3340. DOI: 10.3892/ijmm.2011.653.
[3]	SONG YZ, LI BX, HAO H, et al. Selective screening for inborn errors of metabolism and secondary methylmalonic aciduria in pregnancy at high risk district of neural tube defects: A human metabolome study by GC-MS in China[J]. Clin Biochem, 2008, 41(7-8): 616-620. DOI: 10.1016/j.clinbiochem.2008.01.025.
[4]	KOBAYASHI K, ⅡJIMA M, USHIKAI M, et al. Citrin deficiency[J]. J Jpn Pediatr Soc, 2006, 110: 1047-1059.
[5]	KIM Y, CHOI JY, LEE SH, et al. Malfunction in mitochondrial β-oxidation contributes to lipid accumulation in hepatocyte-like cells derived from citrin deficiency-induced pluripotent stem cells[J]. Stem Cells Dev, 2016, 25(8): 636-647. DOI: 10.1089/scd.2015.0342.
[6]	TANG CF, LIU SC, FENG Y, et al. Newborn screening program and blood amino acid profiling in early neonates with citrin deficiency[J]. Chin J Pediatr, 2019, 57(10): 797-801. DOI: 10.3760/cma.j.issn.0578-1310.2019.10.014. 唐诚芳, 刘思迟, 冯毅, 等. 希特林蛋白缺乏症新生儿早期血氨基酸谱特征及新生儿筛查评估[J]. 中华儿科杂志, 2019, 57(10): 797-801. DOI: 10.3760/cma.j.issn.0578-1310.2019.10.014.
[7]	CHEW HB, NGU LH, ZABEDAH MY, et al. Neonatal intrahepatic cholestasis associated with citrin deficiency (NICCD): A case series of 11 Malaysian patients[J]. J Inherit Metab Dis, 2010, 33(Suppl 3): S489-S495. DOI: 10.1007/s10545-010-9248-6.
[8]	SHIGEMATSU Y, HIRANO S, HATA I, et al. Newborn mass screening and selective screening using electrospray tandem mass spectrometry in Japan[J]. J Chromatogr B Analyt Technol Biomed Life Sci, 2002, 776(1): 39-48. DOI: 10.1016/s1570-0232(02)00077-6.
[9]	WANG Y, SUN M. GC/MS based metabonomie study of neonatal hepatitis syndrome[J]. Int J Pediatr, 2018, 45(7): 537-542. DOI: 10.3760/cma.j.issn.1673-4408.2018.07.011. 王洋, 孙梅. 基于气相色谱-质谱联用技术对婴儿肝炎综合征的代谢组学研究[J]. 国际儿科学杂志, 2018, 45(7): 537-542. DOI: 10.3760/cma.j.issn.1673-4408.2018.07.011.
[10]	ZHANG ZH, LIN WX, ZHENG QQ, et al. Molecular diagnosis of citrin deficiency in an infant with intrahepatic cholestasis: Identification of a 21.7kb gross deletion that completely silences the transcriptional and translational expression of the affected SLC25A13 allele[J]. Oncotarget, 2017, 8(50): 87182-87193. DOI: 10.18632/oncotarget.19901.
[11]	SONG YZ, ZHANG ZH, LIN WX, et al. SLC25A13 gene analysis in citrin deficiency: Sixteen novel mutations in East Asian patients, and the mutation distribution in a large pediatric cohort in China[J]. PLoS One, 2013, 8(9): e74544. DOI: 10.1371/journal.pone.0074544.
[12]	LIN WX, ZENG HS, ZHANG ZH, et al. Molecular diagnosis of pediatric patients with citrin deficiency in China: SLC25A13 mutation spectrum and the geographic distribution[J]. Sci Rep, 2016, 6: 29732. DOI: 10.1038/srep29732.
[13]	LIN WX, ZENG HS, ZHANG ZH, et al. Molecular diagnosis of pediatric patients with citrin deficiency in China: SLC25A13 mutation spectrum and the geographic distribution[J]. Sci Rep, 2016, 6: 29732. DOI: 10.1038/srep29732.
[14]	WANG L, CHENG XR, YAN L, et al. Analysis of clinical features and SLC25A13 gene mutations in a family affected with neonatal intrahepatic cholestasis[J]. Chin J Med Genetics, 2016, 33(5): 670-673. DOI: 10.3760/cma.j.issn.1003-9406.2016.05.020. 王玲, 程昕然, 鄢力, 等. 一个Citrin蛋白缺乏所致新生儿肝内胆汁淤积症家系的SLC25A13基因突变分析[J]. 中华医学遗传学杂志, 2016, 33(5): 670-673. DOI: 10.3760/cma.j.issn.1003-9406.2016.05.020.
[15]	ZHANG JL, SHU SN, CAI ZS, et al. Neonatal intrahepatic cholestasis caused by Citrin deficiency with hepatic cirrhosis ascites as the main manifestation: A case report[J]. J Clin Hepatol, 2019, 35(2): 372-375. DOI: 10.3969/j.issn.1001-5256.2019.02.026. 张建玲, 舒赛男, 蔡在胜, 等. 以肝硬化腹腔积液为特征表现的Citrin蛋白缺陷所致新生儿肝内胆汁淤积症1例报告[J]. 临床肝胆病杂志, 2019, 35(2): 372-375. DOI: 10.3969/j.issn.1001-5256.2019.02.026.