Liver International 2003, 23, 315–322 Copyright r Blackwell Munksgaard 2003

Printed in Denmark. All rights reserved

Review Article

Genetic cholestasis, causes and

consequences for hepatobiliary transport
 
 Jansen PLM, Sturm E. Genetic cholestasis, causes and consequences for  Peter L. M. Jansen and Ekkehard
 hepatobiliary transport.  Sturm
 
 Liver International 2003: 23: 315–322. r Blackwell Munksgaard, 2003  Departments of Gastroenterology and
 
  Pediatrics, University Hospital Groningen,
 Abstract: Bile salts take part in an efficient enterohepatic circulation in 
  The Netherlands
 which most of the secreted bile salts are reclaimed by absorption in the 
 
 terminal ileum. In the liver, the sodium-dependent taurocholate transporter 
 
 at the basolateral (sinusoidal) membrane and the bile salt export pump at the 
 
 canalicular membrane mediate hepatic uptake and hepatobiliary secretion of 
 
 bile salts. Canalicular secretion is the driving force for the enterohepatic 
 
 cycling of bile salts and most genetic diseases are caused by defects of 
 
 canalicular secretion. Impairment of bile flow leads to adaptive changes in 
 
 the expression of transporter proteins and enzymes of the cytochrome P-450 
 
 system involved in the metabolism of cholesterol and bile acids. Bile salts act 
 
 as ligands for transcription factors. As such, they stimulate or inhibit the 
 
 transcription of genes encoding transporters and enzymes involved in their 
 own metabolism. Together these changes appear to serve mainly a 
 
 hepatoprotective function. Progressive familial intrahepatic cholestasis 
 
 (PFIC) results from mutations in various genes encoding hepatobiliary 
 
 transport proteins. Mutations in the FIC1 gene cause relapsing or permanent 
 
 cholestasis. The relapsing type of cholestasis is called benign recurrent 
 
 intrahepatic cholestasis, the permanent type of cholestasis PFIC type 1. PFIC 
 
 type 2 results from mutations in the bile salt export pump (BSEP) gene. This 
 
 is associated with permanent cholestasis since birth. Serum gamma-  Key words: benign recurrent intrahepatic cho-
 
 glutamyltransferase (gamma-GT) activity is low to normal in PFIC types 1  lestasis – bile acids – bile acid synthesis – bile
  salt export pump – farnesoid X-receptor –
 and 2. Bile diversion procedures, causing a decreased bile salt pool, have a 
  hepatobiliary transport – intrahepatic cholestasis
 beneficial effect in a number of patients with these diseases. However, liver 
  of pregnancy – progressive familial intrahepatic
 transplantation is often necessary. PFIC type 3 is caused by mutations in the 
  cholestasis
 MDR3 gene. MDR3 is a phospholipid translocator in the canalicular 
  Prof. Peter L. M. Jansen, MD, PhD,
 membrane. Because of the inability to secrete phospholipids, patients with 
  Division of Gastroenterology and Hepatology,
 PFIC type 3 produce bile acid-rich toxic bile that damages the intrahepatic 
  Department of Medicine, University Hospital,
 bile ducts. Serum gamma-GT activity is elevated in these patients.  Hanzeplein 1, 9717 GZ Groningen,
 
 Ursodeoxycholic acid therapy is useful for patients with a partial defect.  The Netherlands.

Liver transplantation is a more definitive therapy for these patients.
Bile salts are the main organic solutes in bile, and
their vectorial secretion from blood to bile
represents the major driving force for bile
formation. Although bile is iso-osmotic in rela-
tion to plasma, bile salts are 100–1000-fold
concentrated in bile, necessitating active trans-
Abbreviations: PFIC 5 progressive familial intrahepatic choles-
tasis; BRIC 5 benign recurrent intrahepatic cholestasis; IC-
P 5 intrahepatic cholestasis of pregnancy; BSEP 5 bile salt
export pump; OATP 5 organic anion transporting polypeptide;
MRP 5 multidrug resistance-related protein; ASBT 5 apical
sodium-dependent bile acid transporter; FXR 5 farnesoid X-
receptor; SHP 5 small heterodimer partner; JNK 5 c-jun N-
terminal kinase.
E-mail: p.l.m.jansen@int.azg.nl
port of bile salts by hepatocytes against a
concentration gradient. The total bile salt pool
size in adult humans amounts to 50–60 mmol/kg
body weight, corresponding to 3–4 g, and is
largely stored in the gallbladder during the
fasting state. The human bile salt pool circulates
6–10 times per 24 h, resulting in a daily bile salt
secretion of 20–40 g. Despite a high degree of
intestinal bile salt conservation, about 0.5 g of
bile salts is lost through fecal excretion. This loss
is compensated for by de novo hepatic bile salt
synthesis, which contributes less than 3% of bile
salts secreted with hepatic bile. The intrinsic link
between intestinal bile salt absorption and
315
Jansen and Sturm
hepatic synthesis has recently been delineated by
the discovery that bile salts are ligands for
transcription factors that affect the expression
of a number of genes involved in bile salt
synthesis and transport. Disturbances of bile salt
transport are important causes of acquired and
genetic forms of cholestatic liver disease in
humans.
Physiology
Hepatic transport proteins
Hepatic uptake
The Na1/taurocholate co-transporting polypep-
tide (NTCP; SLC10A1) is the major bile salt
uptake system of hepatocytes (1) (Fig. 1). It is
localized in the basolateral membrane of hepa-
tocytes (2). Ntcp in rats preferentially mediates
sodium-dependent transport of conjugated bile
salts, such as taurocholate (capital letters, NTCP,
are used to denote the human transporter and
lowercase letters, Ntcp, the rodent protein). This
transport comprises the major fraction of hepatic
bile salt uptake. NTCP is not the only hepatic
uptake transporter for bile salts. OATP-C
(SLC21A6) transports a number of organic
anions, including bilirubin and bile salts, in a
sodium-independent manner. OATP-B, OATP-C
and OATP8 exhibit broad overlapping substrate
specificities and together account for drug
clearance by human liver (3).
Canalicular bile salt transport
The human bile salt export pump (BSEP,
ABCB11) is critical for ATP-dependent transport
of bile acids across the hepatocyte canalicular
membrane and for the generation of bile acid-
dependent bile secretion (4). Murine Bsep was
shown to transport taurocholate, taurocheno-
deoxycholate and glycocholate (5, 6). Bsep ( / )
knockout mice are cholestatic in the sense
that taurocholate accumulates in their plasma
because its secretion into bile is strongly impaired
(italics denote the gene, non-italics the protein)
(7). However, in contrast to patients, the mice
excrete substantial amounts of tauromuricholate
as well as tetrahydroxy bile salts via hitherto
undefined canalicular transporters. Humans are
not capable of converting bile salts into mur-
icholate or tetrahydroxy bile salts to any sig-
nificant extent; therefore, this escape route is not
available to man.
Basolateral escape routes
MRP3 (ABCC3), MRP4 (ABCC4) and MRP1
(ABCC1) are transporter proteins that support
the basolateral export of organic anions, includ-
316
PFIC 3
MRP3 MRP1 MRP4
OATP-A
OATP-B
OATP-C
MDR3 MDR1
OATP8 BSEP
FIC1
NTCP MRP2 PFIC 1/BRIC
OCT1 Liver
PFIC 2
Dubin Johnson Synd.
MRP3 MRP1
ASBT Intestine
MRP2 MDR1
Fig. 1. Human hepatobiliary transport proteins involved in bile
formation, secretion and reabsorption. Transporter proteins
located in the basolateral membrane are responsible for hepatic
uptake of bile salts (NTCP, OATPs), bulky organic anions,
uncharged compounds (OATPs) and cations (OATPs, OCT1).
Transporter proteins located in the canalicular membrane are
responsible for the biliary secretion of bile salts, phosphatidyl-
choline, cholesterol and glutathione and the excretion of drugs
and toxins. These are the bile salt export pump BSEP (ABCB11),
the phosphatidylcholine translocator MDR3 (ABCB4), the
multispecific organic anion transporter MRP2 (ABCC2) and
the multidrug transporter MDR1 (ABCB1). The organic anion
transporters MRP3 (ABCC3), MRP4 (ABCC4) and MRP1
(ABCC1) are present at very low levels in normal human liver
but their expression is strongly increased during cholestasis.
Both MRP3 and MRP4 are able to transport bile acid
conjugates out of the hepatocyte. FIC1 (ATP8B1) has been
characterized as an aminophospholipid translocase. In the
terminal ileum, the apical sodium-dependent bile acid transpor-
ter (ASBT) is responsible for bile acid reabsorption. Genetic
defects have been described for FIC1 (PFIC type 1, BRIC),
BSEP (PFIC type 2), MDR3 (PFIC type 3, ICP), MRP2
(Dubin–Johnson syndrome) and ASBT (bile acid malabsorp-
tion).
ing that of bile acid conjugates (8, 9). In normal
liver their expression is low, but in cholestasis
these proteins are highly expressed (10, 11). It is
postulated that these proteins play a role as
basolateral escape transporters when canalicular
Bsep function is impaired as during sepsis, drug-
induced cholestasis or bile duct obstruction.
Intestinal reabsorption
In the ileum, bile salts are reabsorbed. A sodium-
dependent apical bile salt transporting protein
ASBT (SLC10A2) and an intracellular bile salt
binding protein play an important role in
reclaiming bile salts from the intestinal lumen,
but other mechanisms for bile salt reabsorption
probably co-exist (12, 13). About 90% of the
total biliary bile salts are reabsorbed in the ileum.
Mechanisms of adaptation
Hepatocytes are strictly polarized cells. They
absorb substrates from the blood and secrete
metabolites into the bile. The supply of bile acids
 Genetic cholestasis, causes and consequences for hepatobiliary transport
is highly variable. Absorption of bile salts by the
liver from the portal venous blood is nearly
complete and, in the fasting state, mainly occurs
in periportal hepatocytes. Thus, periportal hepa-
tocytes are continuously exposed to high bile salt
concentrations. Hepatocytes more downstream
into the hepatic acinus are exposed to varying
concentrations of bile salts: low in the fasting
state, high after a meal. Bile salts are cytotoxic
and cellular homeostasis demands maintenance
of intracellular bile salt concentrations within
certain limits. Post-translational regulations with
recruitment of BSEP from intracellular stores to
the canalicular membrane may be operational for
this purpose (14). Obstruction of bile efflux by
gallstones or tumors will lead to a more chronic
exposure of liver cells to bile salts. Transcrip-
tional regulation enables alterations of BSEP
expression in order to maintain cellular home-
ostasis. Cytokines also play a role here. Bile salts
stimulate Kupffer cells to produce TNF-a and
interleukin-1b. These act upon hepatocyte recep-
tors that affect the c-jun N-terminal kinase signal
transduction pathway.
Regulation of gene expression
Nuclear hormone receptors have been identified
as important transcription factors in lipid and
bile salt metabolism. The BSEP gene is under the
transcriptional control of FXR (farnesoid X-
receptor) (Fig. 2) (15). FXR is a ligand-activated
transcription factor. Chenodeoxycholic acid and
cholic acid bind and activate FXR (Fig. 2 (1)).
Subsequently, FXR forms a heterodimer with
RXR (retinoid X-receptor) and translocates to
the nucleus (2). Here the FXR:RXR heterodimer
acts as a transcription factor of e.g. the BSEP
and SHP-1 (small heterodimer protein-1) genes.
SHP-1 antagonizes the transcription of CYP7A1,
CYP8B and NTCP (16, 17). Thus, FXR controls
several key steps in bile salt metabolism. Studies
in mice with a genetic disruption of Fxr showed
that the Fxr-mediated response is particularly
important in dealing with a bile salt load as
occurs when mice are fed a high cholesterol- or
cholate-containing diet. In Fxr null mice, the
expression of the Ntcp, Cyp7a1 and Cyp8b genes
fails to be downregulated and the expression of
the Bsep and Shp-1 genes is not increased (18).
Severe hepatic damage is the consequence of this
failure of regulation.
Cholestasis in rats is associated with a
decreased expression of Ntcp (19). This in part
results from enhanced expression of Shp-1
through activation of Fxr by retained bile salts
(17), but also Shp-1-independent pathways exist
to suppress transcription of the Ntcp and Cyp7a1
MRP3
CHOLESTEROL
CYP7A1
CYP 8B1
NTCP BSEP
Bile Acids [1]
+
+
[2] FXR:RXR BSEP
FXR:RXR [3]
SHP-1
FXR:RXR
JNK TNFα/ILβ
SHP-1
NTCP -
-
SHP-1
CYP7A1
+
LRH-1
MRP3
Fig. 2. Gene regulation by bile salts. Bile salts are taken up in the
liver by NTCP and secreted into bile by canalicular BSEP. In
cholestasis BSEP activity is reduced the intracellular bile salt
concentration increases (1). Bile salts serve as ligands for FXR,
which forms a heterodimer with RXR and translocates to the
nucleus (2). The heterodimer activates the transcription of the
BSEP and SHP-1 genes. SHP-1 antagonizes the expression of
the bile acid biosynthetic enzymes CYP7A1 and CYP8B1 and
the transporter NTCP. In addition, Kupffer cells produce TNF-
a and interleukin-1b during cholestasis and, via the c-Jun N-
terminal kinase-dependent (JNK) pathway, they reduce the
expression of NTCP and CYP7A1 (3). Recent evidence indicates
that Lrh-1 (liver receptor homolog-1)-mediated Mrp3 transcrip-
tion is enhanced via a TNF-a signalling pathway (25). Thus, at
increasing bile salt concentrations, de novo synthesis is reduced,
uptake is impaired and secretion, either across the canalicular or
basolateral membrane, is stimulated. As a consequence, the
intracellular bile salt concentration remains controlled and
limited.
genes (20, 21). In some of these, cytokines play an
important role, but a recent study indicates that
FXR can also suppress the Cyp7a1 gene in an
Shp-1-independent way (21). This again indicates
the key role of bile acids in these adaptations.
Also in humans, NTCP expression in cholestatic
liver disease is decreased (22). Downregulation of
the NTCP and CYP7A1 genes, and the cons-
quent decreased expression of NTCP and
CYP7A1, in cholestatic liver disease reduces the
entry and the synthesis of bile acids. This
regulation most probably serves a cytoprotective
function. This is particularly important in the
case of bile duct obstruction when BSEP, via
FXR-stimulated expression of its gene, remains
active and keeps transporting bile acids into the
bile canaliculus despite the downstream obstruc-
tion. This leads to disruption of tight junctions
and bile infarcts (23). Up-regulation of MRP1, 3
and 4 in the basolateral membranes of hepato-
cytes probably constitutes an important escape
route for the cellular release of cholestatic
products. Bile salts, bilirubin and cytokines are
involved in the transcriptional activation of their
respective genes (11, 24, 25).
317
Jansen and Sturm
Pathophysiology
Genetic transport defects
The spectrum of diseases caused by defects of
ABC transporter proteins is diverse and includes
the liver diseases: progressive familial intrahepa-
tic cholestasis (PFIC) (26) (Table 1), benign
recurrent intrahepatic cholestasis (BRIC) (27),
intrahepatic cholestasis of pregnancy (28, 29),
intrahepatic gallstone formation (30), cystic
fibrosis (31), adrenoleukodystrophy (32) and
Dubin–Johnson syndrome (33, 34).
PFIC constitutes a group of autosomal recessive
diseases characterized by cholestasis starting in
infancy. For a first differentiation of various PFIC
subtypes, measurement of the serum gamma-
glutamyltransferase (gamma-GT) activity is useful.
Diseases associated with a low bile salt concentra-
tion in bile have a low serum gamma-GT activity.
These diseases have an intrahepatocellular block-
ade of bile salt secretion in common. Gamma-GT
in human liver is mainly located in the membranes
lining the biliary tree. Elevation of serum gamma-
GT results from a detergent, membranolytic effect
of bile salts on these membranes. Thus an intra- or
extrahepatic obstruction of bile flow, or bile devoid
of phosphatidylcholine (as in PFIC type 3, see
below), causes gamma-GT to be released in the
circulation.
PFIC type 1
PFIC type 1 or Byler disease often begins with
cholestatic episodes progressing to permanent
cholestasis with fibrosis, cirrhosis and liver failure
in the first two decades of life (35). Children with
PFIC type 1 are small for their age and, in
addition to cholestasis and pruritus, they often
have diarrhea and occasionally pancreatitis. The
larger bile ducts are anatomically normal and
liver histology shows bland canalicular cholesta-
sis without much bile duct proliferation, inflam-
mation, fibrosis or cirrhosis (35, 36). On electron
microscopy, there is a paucity of canalicular
microvilli and a thickened pericanalicular net-
work of microfilaments. The coarse granular bile
in the canaliculi is called ‘Byler bile’. Character-
istically, the serum gamma-GT activity is not
elevated while primary bile salt levels, in parti-
cular chenodeoxycholic acid, are increased. Ser-
um cholesterol is usually normal. Patients
belonging to the Byler kindred are descendants
of Jacob and Nancy Byler, who emigrated in the
late 18th century from Germany to the United
States. The PFIC syndrome has also been
described in families in the Netherlands, Sweden,
Greenland and an Arab population (35, 37–40).
318
BRIC
Recurrent familial intrahepatic cholestasis is also
known under the name BRIC or Summerskil
syndrome. Despite recurrent attacks of cholesta-
sis, there is no progression to chronic liver disease
in a majority of patients. During the attacks, the
patients are severely jaundiced and have pruritus,
steatorrhoea and weight loss. As in PFIC 1 the
serum gamma-GT is not elevated. Some patients
also have renal stones, pancreatitis and diabetes.
The gene involved in recurrent familial intrahe-
patic cholestasis has been mapped to the FIC1
locus (27). This suggests that recurrent familial
intrahepatic cholestasis and PFIC type I are
genetically related. However, in not all BRIC
patients could the defect be traced to chromo-
some 18 mutations (41). Ursodeoxycholic acid is
of no benefit in BRIC (42). Case reports indicate
that rifampicine may reduce the number of
cholestatic episodes (43, 44).
PFIC type 2
Genetic studies revealed a number of PFIC
patients in whom the FIC1 locus does not seem
to be involved. In a large number of non-Amish
patients, the disease was mapped to a locus on
chromosome 2q24, which later proved to be the
ABCB11 (BSEP) gene (45). Antibodies directed
against BSEP showed that the protein is located
in the canalicular domain of the hepatocyte
plasma membrane. Liver specimens of patients
with PFIC type 2 stain negative for canalicular
BSEP on immunohistochemistry using BSEP
antibodies (46). As in PFIC type 1, the serum
gamma-GT activity in these patients is not
elevated and bile duct proliferation is absent.
However, there are also some differences with
PFIC type 1: in PFIC2 the disease often starts as
nonspecific giant cell hepatitis, which is indis-
tinguishable from idiopathic neonatal giant cell
hepatitis; patients are frequently jaundiced and
the disease rapidly progresses to persistent and
progressive cholestasis requiring liver transplan-
tation within the first decade. The liver histology
shows more inflammation than in PFIC type 1,
with giant cell transformation, lobular and portal
fibrosis (35). The bile of PFIC type 2 patients is
amorphous or filamentous on transmission elec-
tron microscopy. This contrasts with the coarsely
granular bile of PFIC type 1 patients. Extra-
hepatic manifestations are uncommon.
PFIC type 3
The third PFIC subtype, PFIC type 3, is quite
different from the other PFIC subtypes. In patients
 Genetic cholestasis, causes and consequences for hepatobiliary transport
Table 1. Genetic cholestasis

Disease Chromosome Gene Phenotype Therapy

PFIC type 1 18q21 FIC 1 (ATP8B1) P-type ATPase, First recurrent, later permanent Ursodeoxycholic acid, bile
acts as an aminophospholipid cholestasis, bile duct proliferation diversion, liver transplantation
translocator is a late phenomenon. Diarrhea,
pancreatitis, pruritus, short
stature. Coarse granular bile on
EM. Normal gamma-GT
Benign recurrent 18q21 FIC1 (ATP8B1) Recurrent episodes of cholestasis Cholestyramine and/or
intrahepatic with severe pruritus, steatorrhea rifampicine as symptomatic
cholestasis and weight loss. Normal gamma- antipruritus therapy
GT
PFIC type 2 2q24 BSEP (ABCB11), bile salt export Neonatal hepatitis, progressive Ursodeoxycholic acid bile
pump cholestasis, pruritus, short diversion, liver transplantation
stature, bile duct proliferation is a
late phenomenon, lobular and
portal fibrosis. BSEP protein
absent. Amorphous bile on EM.
Normal gamma-GT
PFIC type 3 7q21 PGY3 (ABCB4, MDR 3), P- Cholestasis, portal hypertension, Ursodeoxycholic acid, liver
glycoprotein 3 extensive bile duct proliferation transplantation
and periportal fibrosis. MDR3 is
not expressed. Elevated gamma-
GT
Intrahepatic e.g. 7q21 e.g. MDR3 Cholestasis in third trimester of Ursodeoxycholic acid causes
cholestasis of pregnancy. High gamma-GT in symptomatic relief in the mother
pregnancy case of MDR3 defect; low and decreases fetal loss
gamma-GT cases may be caused
by genetic defects of other
transporter proteins. High
incidence of fetal loss
Aagenaes syndrome 15q LCS1, LCS2 Episodic cholestasis, Liver transplantation but
lymphedema, normal gamma-GT persistence of lymphedema
Familial 9q12–q13 9q22– TJP2/ZO-2 BAAT Elevated bile acids, severe Liver transplantation
Hypercholanemia q32 pruritus, fat malabsorption,
failure to thrive, rickets, vitamin K
coagulopathy
Bile acid synthesis e.g. 8q2.3 3b-D5-C27-hydroxysteroid Intrahepatic cholestasis, neonatal Ursodeoxycholic acid,
defects oxidoreductase; D4-3- giant cell hepatitis. Normal or chenodeoxycholic acid or cholic
oxosteroid-5b reductase; 3b- elevated gamma-GT, low or acid alone or in combination,
hydroxy C27 steroid elevated serum total bile acids depending on subtype
dehydrogenase/isomerase;
oxysterol 7a-hydroxylase; 24,25-
dihydroxy-cholanoic cleavage
enzyme.

gamma-GT 5 gamma glutamyl tranferase.

with PFIC type 3, symptoms present somewhat
later in life than in PFIC types 1 and 2, and liver
failure also occurs at a later age. Jaundice may be
less apparent during the early stages of disease. The
serum gamma-GT activity is usually markedly
elevated in these patients and the liver histology
shows extensive bile duct proliferation, portal and
periportal fibrosis (47, 48). In humans, the MDR3
gene is mutated in this disease (28, 29, 47, 48).
Patients with a partial MDR3 defect often respond
to ursodeoxycholic acid therapy (49). The majority
of patients, particularly those with a complete
defect, have to be transplanted.
Therapy
Subgroups of PFIC types 1–3 may respond to
ursodeoxycholic acid (50). However, progression
of disease and insufficient control of symptoms
may necessitate further intervention such as liver
transplantation. Ursodeoxycholic may also lead
to acceleration of disease (50) or to very high
serum bile acid levels (41 mmol/l) without any
increase of bile salt secretion (46). PFIC 3
patients are more likely to respond to ursodeoxy-
cholic acid therapy if they carry mild mutations
of the MDR3 gene (48, 49).
For PFIC types 1 and 2, partial external biliary
diversion is an accepted mode of therapy (51, 52).
The majority of patients respond with a significant
improvement of symptoms (52–54). When per-
formed early, ongoing hepatic injury may be
interrupted with resolution of histological abnorm-
alities including reversal of fibrosis (54). Clinically,
the patients may experience long-term amelioration
of pruritus and induction of catch-up growth (52).

319
Jansen and Sturm
Liver transplantation has been performed for
patients with PFIC types 1–3. In general, these
patients have a good prognosis after successful
transplantation (55). Since PFIC type 1 is a
multiorgan disease, diarrhea may persist and
pancreatitis may occur after transplantation.
Diarrhea in these patients is associated with
malabsorption; therefore, catch-up growth after
transplantation may be disappointing.
Intrahepatic cholestasis of pregnancy (ICP)
Jacquemin et al. (29) reported a high incidence of
ICP in families with PFIC type 3. This suggests
that in persons carrying one mutated MDR3
gene, cholestasis may occur during pregnancy.
Mutations leading to single amino acid substitu-
tions of the MDR3 protein may cause intracel-
lular traffic mutants, i.e. the protein is
synthesized but does not reach its destination in
the canalicular membrane (56). ICP has also been
described in families with other PFIC subtypes
(57). Thus, ICP may be associated either with
elevated serum gamma-GT or with a normal
enzyme activity. Ursodeoxycholic acid has been
shown to be of benefit in these patients, with also
a decrease of fetal loss (58, 59).
Other forms of intrahepatic cholestasis
Aageneas syndrome is a combination of severe
progressive lymphedema and episodic intrahepa-
tic cholestasis (60). The locus for this disease has
been mapped to one locus, or perhaps two loci,
on chromosome 15q (61, 62). Recently, Carlton
et al. (63) described patients with familial
hypercholanemia characterized by elevated ser-
um bile acids, pruritus, fat malabsorption, failure
to thrive, rickets and vitamin K coagulopathy.
This disease is associated with a mutation of the
tight-junction protein 2 gene (TJP2 or ZO-2)
with or without additional mutations in a gene
encoding the bile acid coenzyme A:amino acid N-
acyltransferase gene (BAAT). Patients with TJP2
mutations had higher gamma-GT serum levels
than patients with BAAT gene mutations only.
The serum of patients with BAAT mutations did
not contain bile acid amino acid conjugates.
Acknowledgements
This research was supported by the Netherlands Organization
for Scientific Research, NWO program grant 902-23-191 and
NWO project grants 902-23-253, 902-23-257 and 903-39-188.
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