A multidrug resistance 3 gene mutation causing cholelithiasis, cholestasis of pregnancy, and adulthood biliary cirrhosis.
We describe a 47-year-old patient who developed cholelithiasis in adolescence, followed by recurrent intrahepatic cholestasis of pregnancy, and finally biliary cirrhosis in adulthood. In our patient, the consecutive presentation of the 3 mentioned disorders raised the suspicion of a defect of MDR3, the canalicular protein involved in the transport of phospatidylcholine to bile. Mutational analysis in our patient showed a heterozygous missense mutation of the MDR3 gene that has not been described previously, which occurs in exon 14 at codon 535, and results in the substitution of glycine for aspartic acid. Further analysis of 7 members of the family showed the same mutation in her daughter who, on follow-up, developed cholestasis of pregnancy and persisting high serum levels of gamma-glutamyl transpeptidase and alkaline phosphatase after delivery. Although biliary cirrhosis associated with MDR3 deficiency typically appears before the age of 25 years, in our case, the relatively mild MDR3 dysfunction allowed for a slower progression of the disease with established, well-advanced cirrhosis in the fifth decade of life. The present case, which accumulates the 3 clinical disorders assocaited with MDR3 deficiency, shows that this condition should be suspected not only in children or young people with high gamma-glutamyl transpeptidase cholestasis but also in middle-aged or older patients with chronic idiopathic cholestasis, especially when there is a previous history of cholestasis of pregnancy or juvenile cholelithiasis.
Lucena
Juan-Felipe
JF
Clinica Universitaria and Medical School, University of Navarra, Medicine and Liver Unit, Pamplona, Navarra, Spain.
Herrero
J Ignacio
JI
Quiroga
Jorge
J
Sangro
Bruno
B
Garcia-Foncillas
Jesus
J
Zabalegui
Natalia
N
Sola
Josu
J
Herraiz
Maite
M
Medina
Juan F
JF
Prieto
Jesus
J
D018435:ATP Binding Cassette Transporter, Subfamily B / Q000032:analysis / Q000235:genetics*; D018528:ATP-Binding Cassette Transporters / Q000032:analysis / Q000235:genetics*; D000367:Age Factors; D002769:Cholelithiasis / Q000235:genetics* / Q000473:pathology; D002779:Cholestasis / Q000235:genetics* / Q000473:pathology; D004252:DNA Mutational Analysis; D005260:Female; D006801:Humans; D007150:Immunohistochemistry; D008099:Liver / Q000737:chemistry / Q000473:pathology; D008105:Liver Cirrhosis, Biliary / Q000235:genetics* / Q000473:pathology; D008875:Middle Aged; D010375:Pedigree; D011247:Pregnancy; D011248:Pregnancy Complications
D018435:ATP Binding Cassette Transporter, Subfamily B; D018528:ATP-Binding Cassette Transporters; C095122:multidrug resistance protein 3